THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


THE  THYROID  GLAND 

CLINICS  OF 
GEORGE   W.  GRILE 

AND 

ASSOCIATES 


EDITED  BY 

AMY   F.  ROWLAND 


WITH  106  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1922 


Copyright,  1922,  by  W.  B.  Saunders  Company 


MADE     IN     u.     S.     A. 

PRESS     OF 

W.     B.     SAUNDERS     COMP 
PHILADELPHIA 


WK 

20.0 


LIST  OF  CONTRIBUTORS 


CHESTER  D.  CHRISTIE,  M.  D.,  Instructor  in  Medicine,  Western 
Reserve  University;  Assistant  Visiting  Physician,  Lakeside 
Hospital. 

GEORGE  W.  CHILE,  M.  D.,  F.  A.  C.  S.,  Professor  of  Surgery, 
Western  Reserve  University;  Visiting  Surgeon,  Lakeside  Hos- 
pital; Surgical  Director,  Cleveland  Clinic. 

FRANK  D'HOUBLER,  M.  D.,  Special  Resident,  Lakeside  Hospital. 

ROBERT  S.  DINSMORE,  M.  D.,  Third  Resident  Surgeon,  Lakeside 
Hospital. 

FRANK  S.  GIBSON,  M.  D.,  First  Resident  Surgeon,  Lakeside  Hos- 
pital. 

WILLIAM  R.  GOFF,  M.  D.,  Second  Resident  Surgeon,  Lakeside 
Hospital. 

ALLEN  GRAHAM,  M.D.,F.  A.C.S.,  Instructor  in  Surgery,  Western 
Reserve  University;  Assistant  Visiting  Surgical  Pathologist, 
Lakeside  Hospital. 

AGATHA  HODGINS,  R.  N.,  Chief  Anesthetist,  and  Head  of  School  of 
Anesthesia,  Lakeside  Hospital. 

O.  P.  KIMBALL,  M.  D.,  Assistant  in  Division  of  Medicine.,  Cleve- 
land Clinic. 

WILLIAM  E.  LOWER,  M.  D.,  F.  A.  C.  S.,  Associate  Professor  of 
Genito-urinary  Surgery,  Western  Reserve  University;  Sur- 
gical Director,  Mount  Sinai  Hospital;  Associate  Surgeon  in 
charge  of  Genito-urinary  Surgery,  Lakeside  Hospital;  Sur- 
gical Director,  Cleveland  Clinic. 

BERNARD  H.  NICHOLS,  M.  D.,  Roentgenologist,  Cleveland  Clinic. 

3 


4  LIST   OF   CONTRIBUTORS 

JOHN  PHILLIPS,  M.  B.,  Assistant  Professor  of  Therapeutics,  West- 
ern Reserve  University;  Consulting  Physician,  St.  John's 
Hospital;  Medical  Director,  Cleveland  Clinic. 

ABBIE  R.  PORTER,  R.  N.,  Head  Nurse,  Private  Pavilion,  Lakeside 
Hospital. 

EMMETT  O.  RUSHING,  M.  D.,  Resident  Gynecologist,  Lakeside 
Hospital. 

BLANCHE  E.  SNYDER,  R.  N.,  Operating  Room  Supervisor,  Lake- 
side Hospital. 

JUSTIN  M.  WAUGH,  M.  D.,  F.  A.  C.  S.,  Laryngologist  and  Otologist, 
Cleveland  Clinic. 


CONTENTS 


PAGE 

Introduction 17 

The  Function  of  the  Thyroid 21 

GEORGE  W.  CHILE 

A  Physical  Interpretation  of  the  Role  of  the  Adrenals 

in  Exophthalmic  Goiter 27 

GEORGE  W.  CRILE 

Partial  Hyperthyroidism 31 

GEORGE  W.  CHILE 

Diseases  and  Pathology  of  the  Thyroid  Gland 35 

ALLEN  GRAHAM 

Normal  Thyroid 36 

Hypertrophy  and  Hyperplasia 38 

Colloid  Goiter 39 

Exhaustion,  Atrophy,  and  Fibrosis 40 

Adenoma,  Benign 41 

Adenoma,  Malignant. .  . 43 

Carcinoma 45 

Sarcoma 47 

Inflammations 48 

Cardiac  Disturbances  Associated  with  Disease  of  the 

Thyroid  Gland ! 49 

JOHN  PHILLIPS 

Introduction 49 

The  Relation  of  Adenomata  to  Cardiac  Disturbances 50 

The  Relation  Between  Diseases  of  the  Thyroid  Gland 

and  Laryngeal  Function 55 

JUSTIN  M.  WAUGH 

Differential  Diagnosis  of  Diseases  of  the  Thyroid  Gland  65 

JOHN  PHILLIPS 

Simple  Goiter 67 

Colloid  Goiter 68 

Intrathoracic  Goiter 70 

Adenoma  of  the  Thyroid 81 

Exophthalmic  Goiter  or  Hyperthyroidism 82 

Differential  Diagnosis  of  Hyperthyroidism 88 

Myxedema 89 

Tumors  of  the  Thyroid 94 

Inflammation  of  the  Thyroid  Gland  (Thyroiditis  or  Strumitis) ....  96 

5 


6  CONTENTS 

PAGE 

Adrenalin  Sensitization  Test  for  Hyperthyroidism 99 

ROBERT  S.  DINSMORE 

Subjective  Symptoms 102 

Conclusions 103 

A  Serum  Test  for  Exophthalmic  Goiter 105 

FRANK  D'HOUBLER 

Technic 105 

Theory 106 

Practical  Application 107 

The  Role  Played  by  the  Radiologist  in  the  Diagnosis  of 

Goiter 109 

BERNARD  H.  NICHOLS 

Methods  of  Examination 114 

Summary 139 

The  Value  of  Basal  Metabolism  Studies  in  Exoph- 
thalmic Goiter 141 

CHESTER  D.  CHRISTIE 

Definition 142 

Normal  Factors  which  Affect  the  Metabolic  Rate 144 

Abnormal  Conditions  which  Cause  an  Increase  in  Basal  Metabolism  146 

Basal  Metabolism  in  Exophthalmic  Goiter 147 

Conditions  which  Give  Rise  to  a  Decrease  in  Basal  Metabolism.  .  157 

Bibliography 158 

The  Prevention  of  Simple  Goiter  in  Man 159 

O.    P.    KlMBALL 

Definition  and  History  of  Endemic  Goiter 160 

Distribution 161 

Incidence  of  Goiter  in  the  United  States 163 

The  Physiology  of  the  Thyroid 166 

The  Prevention  of  Goiter 169 

Etiology  of  Endemic  Goiter 171 

Practical  Application  of  the  Principle  of  Goiter  Prevention 173 

Effect  of  Prophylactic  Treatment 175 

Method  and  Form  of  Administration 178 

Possible  111  Effects 180 

The  Possibility  of  the  Elimination  of  Endemic  Goiter  Throughout 

the  World 180 

Bibliography 182 

Surgery  vs.   z-Ray  in   the  Treatment   of  Hyper thy: 

roidism 185 

GEORGE  W.  CHILE 

Preoperative  Management  of  Exophthalmic  Goiter. ...  195 

W.  R.  GOFP  AND  E.  O.  RUSHING 

Introduction  of  the  Patient  to  Hospital  Activities 195 

Preliminary  Examinations,  Tests,  and  Therapy 196 

Preoperative  Routine 198 


CONTENTS  7 

PAGE 

The  Role  of  the  Nurse  in  the  Preoperative  and  Post- 
operative Care  of  the  Patient  with  Exophthal- 
mic Goiter 201 

ABBIE  R.  PORTER 

The  Role  of  the  Operating-room  Nurse  in  Operations 

on  the  Thyroid  Gland 207 

BLANCHE  E.  SNTDER 

The  Administration  of  Nitrous  Oxid-oxygen  Analgesia 

in  Operations  on  the  Thyroid  Gland 213 

AGATHA  HODGKINS 
Plain  Goiters 213 

Exophthalmic  Goiter 214 

Special  Notes '. 218 

Summary 222 

The  Technic  of  Operations  on  the  Thyroid  Gland ....  223 

GEORGE  W.  CHILE  AND  W.  E.  LOWER 

The  Typical  Ligation 223 

The  Typical  Resection  of  the  Thyroid  Gland 228 

Special  Comments 242 

Certain  Postoperative  Complications  of  Operations  on 

the  Thyroid  Gland 253 

GEORGE  W.  CHILE  AND  W.  E.  LOWER 

Treatment  of  Inoperable  Cancer  of  the  Thyroid  by 

Decompression 259 

GEORGE  W.  CHILE 

The   Postoperative   Treatment   of   the   Exophthalmic 

Goiter  Patient 263 

FRANK  S.  GIBSON 

A  Discussion  of  Some  Methods  of  Procedure  which  are  Simple, 
Applicable  to  All  Postoperative  Cases,  and  Therefore  are 
Routinely  Employed 264 

Methods  for  the  Treatment  of  Certain  Postoperative  Complications      267 

The  Protection  of  the  Patient  in  Surgery  of  the  Thyroid  273 

GEORGE  W.  CHILE 

Index.  .  283 


LIST  OF  ILLUSTRATIONS 


1  Increase  in  electric  conductivity  of  the  cerebrum 

and  the  cerebellum  produced  by  iodoform  and  by 
thyroid  feeding 22 

2  Comparison  of  the  effects  on  the  temperature  of  the 

brain  of  the  injection  of  adrenalin  in  normal  and 

in  iodized  animals 24 

3  Early  and  late  effects  of  various  forms  of  stimula- 

tion on  the  electric  conductivity  of  the  cerebrum    28 

4  Hypertrophy  and  hyperplasia  of  the  thyroid  gland    37 

5  Fetal  adenoma  in  various  stages 42 

6  Malignant  adenoma 44 

7  Various  malignant  types  of  thyroid  disease 46 

8  Adolescent  goiter 67 

9  Enormous  diffuse  simple  goiter 68 

10  Colloid  goiter 68 

11  Colloid  goiter 69 

12  Pendulous  goiter 69 

13  Intrathoracic  goiter 71 

14  Substernal  goiter  with  two  metastatic  abscesses  in 

lungs 71 

15  Venous  thrombosis  from  obstruction  due  to  intra- 

thoracic  goiter 73 

16  Radiograph  of  patient  shown  in  Fig.  15,  showing 

well-defined  outline  of  intrathoracic  goiter 76 

17  Radiograph  of  patient  shown  in  Fig.  15,  oblique 

view 77 

18  Autopsy    specimen    from    case    of    intrathoracic 

goiter  described  in  text 79 

9 


10  LIST   OF   ILLUSTRATIONS 

FIG.  PAGE 

19  Multiple  adenomata  of  the  thyroid 81 

20  Adenoma  of  the  thyroid 81 

21  Typical  case  of  exophthalmic  goiter 83 

22  Lack  of  pigmentation  of  skin  sometimes  associated 

with  hyperthyroidism 86 

23  Congenital  myxedema.    Typical  case 90 

24  Typical  case  of  infantilism  due  to  hypopituitarism.  94 

25  External  appearance  of  malignant  goiter 95 

26  External  appearance  of  malignant  goiter 96 

27  Schematic  drawings  illustrating  different  types  of 

compression  of  trachea  produced  by  goiter 109 

28  Schematic  drawings  illustrating  different  types  of 

compression  of  trachea  produced  by  goiter 110 

29  Encircling  goiter  with  posterior  compression  of  the 

trachea Ill 

30  Partially  intrathoracic  median  spiral  goiter  with 

anterior  pressure  on  trachea 112 

31  Intrathoracic  bilateral  goiter  with  bilateral  pressure 

on  trachea 112 

32  Partially  intrathoracic  goiter 113 

33  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  showing  compression  of  trachea  by 
goiter  and  aortitis 114 

34  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  intrathoracic  goiter  showing  dis- 
placement of  trachea  toward  the  left 115 

35  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  intrathoracic  goiter 116 

36  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  intrathoracic  goiter  showing  saber- 
sheath  trachea 117 

37  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  intrathoracic  goiter 118 


LIST    OF    ILLUSTRATIONS  11 

FIG.  PAGE 

38  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  intrathoracic  goiter  with  marked 
displacement  of  trachea 119 

39  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  aortic  aneurysm 120 

40  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  aortic  aneurysm 121 

41  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  aortic  aneurysm  with  trachea  dis- 
placed to  right 122 

42  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  supraclavicular  goiter  and  en- 
larged aorta  with  transverse  heart 124 

43  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  elongated  aorta  with  transverse 
heart 125 

44  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  enlarged  thymus  gland 126 

45  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  enlarged  thymus  gland 127 

46  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  apical  pneumonia 128 

47  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  right  pneumothorax  showing 
trachea,  heart,  and  aorta  displaced  to  the  left 
and  old  fibrous  tuberculosis  of  the  left  lung.  .  .  .  129 

48  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  sarcoma  of  right  lung 130 

49  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  mediastinal  tumor  (lympho- 
sarcoma) 131 

50  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  esophageal  diverticulum 132 


12  LIST   OF   ILLUSTRATIONS 

FIG.  PAGB 

51  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  esophageal  diverticulum 133 

52  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  esophageal  diverticulum 134 

53  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  esophageal  diverticulum 135 

54  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  carcinoma  of  the  esophagus 136 

55  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph  of  carcinoma  of  the  esophagus 137 

56  Differential     diagnosis     of     intrathoracic     goiter. 

Radiograph    of    metastatic    carcinoma    of    the 
mediastinal  glands 138 

57  Comparative  incidence  of  goiter,  simple  and  exoph- 

thalmic, in  the  various  regions  of  the  United 
States 165 

58  Burn  due  to  treatment  of  goiter  with  x-rays 190 

59  Burn  due  to  the  x-ray  treatment  of  the  thyroid 

gland  after  partial  thyroidectomy 191 

60  Operation  in  patient's  room.     Schematic  drawing 

showing  arrangement  of  room  and  position  of 
operating  staff 203 

61  Operation  in  patient's  room.     Position  of  patient 

and  arrangement  of  aseptic  coverings 204 

62  Operation  in  patient's  room.     Patient  ready  for 

operation 205 

63  Schematic  drawing  showing  positions  of  operating 

table,  instrument  tables,  operator,  and  assistants 
for  thyroidectomy 207 

64  Arrangement  of  instruments  on  instrument  table 

for  thyroidectomy 208 

65  Arrangement    of     instruments    and    supplies    on 

nurses'  table  for  thyroidectomy 209 


LIST   OF   ILLUSTRATIONS  13 

FIG.  PAGE 

66  Hot-water  mattress  on  operating  table 209 

67  Extension  reflector  for  illumination  of  field 210 

68  Ligation  of  superior  thyroid  artery.    Infiltration  of 

skin 223 

69  Ligation  of  superior  thyroid  artery.    Deep  infiltra- 

tion for  complete  protection  of  field  of  operation  224 

70  Ligation  of  superior  thyroid  artery.     Line  of  in- 

cision through  fascia 224 

71  Ligation  of  superior  thyroid  artery.    Separation  of 

fibers  of  preglandular  muscles  with  narrow- 
bladed  hemostats 225 

72  Ligation  of  superior  thyroid  artery.     Passage  of 

suture  under  artery  which  is  elevated  with  forceps  225 

73  Ligation  of  superior  thyroid  artery:   A,  Sutures  of 

artery  and  of  superior  pole.  B,  Infiltration  of 
pole  and  of  subcutaneous  tissues  with  quinin  and 
urea  hydrochlorid 226 

74  Ligation  of  superior  thyroid  artery.     Closure  of 

skin  incision  with  clips 226 

75  Typical  charts  showing  that  reaction  to  ligation  is 

no  greater  than  reaction  to  entrance  to  hospital  227 

76  Typical   thyroidectomy.     Position   of   patient   on 

operating-table 229 

77  Operator  and  assistants  ready  to  operate  on  patient 

who  is  being  brought  to  stage  of  analgesia 229 

78  Typical  thyroidectomy.    Distribution  of  novocain 

after  infiltration  by  pressure 230 

79  Typical  thyroidectomy.     Line  of  incision  through 

area  infiltrated  with  novocain 230 

80  Typical  thyroidectomy.    Division  and  reflection  of 

skin 231 

81  Typical  thyroidectomy.     Infiltration  of  pregland- 

ular muscles  before  transverse  incision .  .  232 


14  LIST   OF   ILLUSTRATIONS 

FIO.  PAGE 

82  Typical  thyroidectomy.    Vertical  incision  along  in- 

filtrated line  in  preglandular  muscles.    Skin-flaps 
protected  by  sterile  cloths 233 

83  Typical  thyroidectomy.    Vertical  division  of  pre- 

glandular muscles  exposing  gland 233 

84  Typical   thyroidectomy.     Transverse   division   of 

preglandular  muscles  between  clamps 234 

85  Typical  thyroidectomy.    Infiltration  of  gland  with 

novocain 235 

86  Typical  thyroidectomy.    Posterior  portion  of  gland 

which  is  left  after  thyroidectomy 236 

87  Typical    thyroidectomy.      Schematic    drawing   in 

which  shaded  area  represents  portion  of  gland 
that  is  removed 236 

88  Typical  thyroidectomy.     Suture  of  preglandular 

muscles  with  buttonhole  stitch 238 

89  Typical  thyroidectomy.     Vertical  closure  of  pre- 

glandular muscles 238 

90  Typical  thyroidectomy.     Closure  of  skin  incision 

with  clips 239 

91  Typical  thyroidectomy.     Appearance  of  incision 

after  closure 240 

92  Postoperative  dressing.    Gauze  pad  used  to  protect 

back  of  neck  from  adhesive  plaster 241 

93  Postoperative  dressing,  completely  applied 241 

94  Enlargement  of  median  lobe  after  operation 243 

95  Enlargement  of  upper  portion  of  median  lobe  after 

operation 243 

96  Interrupted  operation.     Wound  packed  with  fla- 

vine  gauze 249 

97  Interrupted  operation.     Deep  infiltration  of  sub- 

cutaneous tissues  before  removal  of  flavine  gauze  250 


LIST    OF   ILLUSTRATIONS  15 


PAGE 


98  Interrupted  operation.    Infiltration  of  muscle-flaps 

with  novocain  before  suture  after  delayed  opera- 
tion with  interim  packing  with  flavine  gauze.  .  .   250 

99  Patient  five  months  after  decompression  operation 

for  carcinoma  of  the  thyroid 260 

100  Chart  illustrating  control  of  postoperative  hyper- 

thyroidism  by  ice-packs 268 

101  Charts  showing  control  of  postoperative  tachy- 

cardia by  digitalin 269 

102  Patient  before  and  after  removal  of  large  bilateral 

goiter 276 

103  Patient  before  and  after  removal  of  large  pendu- 

lous goiter 276 

104  Patient  before  and  after  removal  of  large  vascular 

goiter 277 

105  Patient  before  and  thirty  days  after  removal  of 

adenoma 278 

106  Patient  before  and  after  thyroidectomy  for  exoph- 

thalmic goiter 278 


THE  THYROID   GLAND 


INTRODUCTION 

THE  purpose  of  the  series  of  clinical  volumes  of  which 
this  is  the  first  is  to  present  the  present  theoretic  and 
practical  viewpoints  of  my  associates  and  myself— to  pre- 
sent the  Clinic  at  work.  Both  theory  and  practice,  there- 
fore, will  be  constantly  subject  to  revision  and  possibly 
reversal  of  opinion.  Since  this  is  but  an  ephemeral  publi- 
cation, representing  today's  viewpoint  in  this  Clinic,  and 
does  not  purport  to  be  a  text-book  or  a  monograph,  but 
little  reference  will  be  made  to  the  literature,  excellent  sum- 
maries of  which  are  given  by  Crotti.1 

As  we  have  chosen  the  thyroid  gland  as  our  theme 
for  this  volume,  we  wish  first  of  all  to  express  our  sense 
of  the  obligation  of  medicine  to  Theodore  Kocher  in  Europe 
for  the  secure  foundation  laid  by  him  for  surgery  of  the 
thyroid  gland,  to  the  Mayo  Clinic,  and  to  Marine,  Len- 
hart,  and  Kimball  for  notable  contributions  in  this  field. 

Our  discussion  in  the  following  pages  will  be  centered 
around  the  following  principal  points: 

(a)  Endemic  goiter  is  a  geologic  deficiency  disease  due 

to  a  lack  of  iodin  in  the  organism. 

(&)  By  the  proper  administration  of  iodin  to  the  preg- 
nant mother,  and  to  the  child  up  to  and  through 
the  period  of  adolescence,  endemic  goiter  may  be 
prevented;  that  is  to  say,  the  children  of  goitrous 
regions  may  be  as  goiter  free  as  are  the  children 
of  the  seashore. 

1  Crotti,  A.,  Thyroid  and  Thymus,  1918. 
2  17 


18  THE    THYROID    GLAND 

(c)  After  the  twenty-fifth  year  of  age  iodin  exerts  little 

or  no  beneficial  effect  on  goiters. 

(d)  By  the  improper  use  of  iodin  or  thyroid  products 

many  cases  of  quiescent  goiter,  especially  of  the 
adenomatous  type,  are  converted  into  exophthal- 
mic goiter  or  hyperthyroidism. 

(e)  Induced  hyperthyroidism  is  essentially  identical  with 

spontaneous  hyperthyroidism. 

(/)  About  90  per  cent,  of  all  malignant  tumors  of  the 
thyroid  arise  in  the  fetal  adenomata.  Therefore, 
iodin  given  the  pregnant  mother  may  prevent 
fetal  adenomata,  hence  cancer  of  the  thyroid,  in 
the  offspring. 

(g)  Colloid  goiters,  colloid  adenomata,  and  adenomata 
in  patients  with  normal  sensitization  and  normal 
metabolism  may  be  considered  as  simple  or  quies- 
cent goiters. 

(h)  Hyperthyroidism  may  be  associated  with  a  colloid 
goiter  (rare),  colloid  adenoma,  adenoma,  or  hyper- 
plasia.  Hyperthyroidism  presents  no  uniformly 
specific  pathology  of  the  thyroid  gland. 

(i)  With  certain  exceptions  the  increased  sensitization 
of  the  organism  due  to  hyperthyroidism  is  mani- 
fested by  abnormal  nervousness,  tachycardia, 
tremors,  increased  basal  metabolism,  and  loss  in 
weight. 

0)  With  certain  exceptions  increased  sensitization  due 
to  hyperthyroidism  is  specifically  exaggerated  by 
the  injection  of  adrenalin  (Goetsch  test). 

(k)  Basal  metabolism  estimation  provides  a  valuable, 
but  not  a  specific  test  for  the  presence  of  hyper- 
thyroidism. Basal  metabolism  estimations  are  of 
value  in  the  differential  diagnosis  of  borderline 


INTRODUCTION  19 

cases,  but  are  of  little  value  in  the  determination 
of  the  operability  or  prognosis  of  cases  of  hyper- 
thyroidism. 

(I)  In  a  small  group  of  cases  goiter  may  cause  myo- 
carditis and  hypertension  without  involving  the 
nervous  system. 

(ra)  We  shall  offer  the  general  hypothesis  that  the  body 
is  an  electrochemical  mechanism  in  which  the 
electric  conductivity,  hence  oxidation,  is  controlled 
by  the  thyroid. 

(ri)  We  shall  show  that  the  electric  conductivity  of  cer- 
tain active  tissues  and  organs  is  increased  by  iodin. 
Therefore  we  may  suppose  that  in  all  cases  of 
hyperthyroidism  or  hyperiodism  the  same  tissues 
would  not  be  equally  influenced,  but  that  in  some 
cases  one  and  in  others  another  tissue  would  show 
the  greater  alteration,  thus  producing  such  vari- 
ous types  of  disease  as  the  exophthalmic  type, 
"toxic  adenoma,"  the  myocardial  and  the  cardio- 
vascular types.  Graves'  disease,  Gull's  disease, 
Basedow's  disease,  exophthalmic  goiter,  toxic 
adenoma  are,  at  best,  loose  and  unsatisfactory 
terms. 

(o)  We  shall  develop  the  following  statements  regarding 
the  surgical  treatment  of  hyperthyroidism: 

1.  We  now  believe  that  the  so-called  hyperthyroid- 

ism is  an  intracellular  acidosis  which  is  over- 
come by  restoring  the  normal  acid-alkali  bal- 
ance. This  is  accomplished  by  the  subcutaneous 
infusion  of  from  3000  to  5000  c.c.  of  water;  by 
digitalizing  the  heart;  by  blood  transfusion,  and 
by  rest. 

2.  Any  case  up  to  the  beginning  of  dissolution  is 


20  THE   THYROID   GLAND 

operable,  or  may  be  made  operable  by  a  short 
period  of  active  treatment  which  will  be  de- 
scribed. 

3.  Preliminary  ligations  are  made  in  about  40  per 

cent,  of  the  cases. 

4.  The  average  reaction  following  ligation  is  prac- 

tically the  same  as  the  reaction  which  follows 
admission  to  the  hospital. 

5.  We  no  longer  use  hot- water  injections,   quinin 

and  urea  injections,  rr-ray  or  radium;  but  we 
add  to  surgical  treatment  a  planned  regimen 
of  rest  and  diet  just  as  if  no  operation  had 
been  performed. 

6.  In  view  of  the  surgical  results  we  advise  surgical 

treatment  for  all  cases  without  regard  to  the 
degree  of  hyperthyroidism. 


THE  FUNCTION  OF  THE  THYROID 

GEORGE  W.   CRILE 


THE  brain  drives  the  organisms  of  man  and  animals. 
Environment  drives  the  brain.  The  driving  power  of  the 
brain  depends  principally  upon  three  organs:  the  adrenals, 
the  liver,  and  the  thyroid.  The  contribution  of  the  thyroid 
is  well  illustrated  by  the  two  extremes  of  thyroid  activity: 
myxedema  and  exophthalmic  goiter.  Without  the  thyroid 
the  brain  is  dull  and  stupid.  With  excessive  thyroid  activity 
life  is  exquisitely  tense,  dramatic,  and  excessively  responsive 
to  every  stimulus.  Between  these  extremes  the  mass  of 
humanity  wends  its  normal  way. 

Coincident  with  conditions  of  special  activity  of  the 
organism,  as  in  emotion,  in  infection,  in  bearing  offspring, 
in  exophthalmic  goiter,  the  volume  of  the  thyroid  gland  is 
increased. 

The  peculiar  function  of  the  thyroid  appears  to  be  the 
splitting  up  of  the  iodin-containing  molecules  of  any  com- 
pound of  iodin  which  enters  the  organism  (Marine) — ferrous 
iodid,  sodium  iodid,  potassium  iodid,  and  the  conversion 
of  the  iodin  into  the  specific  thyroid  product — thyro-iodin 
or  thyroxin  (Kendall). 

The  crux  of  the  thyroid  problem,  therefore,  becomes 
this :  What  is  the  fundamental  function  of  iodin  f  In  attacking 
this  question  it  is  necessary  to  adopt  a  new  hypothesis  as 
to  how  the  organism  operates.  We  postulate  that  the  organ- 
ism of  man  and  animals  is  an  electrochemical  mechanism 
which  obeys  physical  laws;  that  the  cells  of  the  nervous 

21 


22 


THE    THYROID    GLAND 


system  are  batteries;  that  the  action  current  of  stimulation 
is  electricity;  that,  in  accordance  with  Nernst's  hypothesis 
and  R.  S.  Lillie's  researches,  the  nerves  are  biologically 
adapted  to  slowing  the  speed  of  transmission;  that  through 
oxidation  electric  energy  is  generated;  that  the  nerve-cell 
as  a  battery  is  active  only  as  long  as  a  difference  in  potential 
between  cell  body  and  nucleus  exists;  that  consciousness  is 
the  act  of  responding  to  the  stimuli  of  the  external  and  the 


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Fig.  1. — Increase  in  electric  conductivity  of  the  cerebrum  and  the  cerebellum 
produced  by  iodoform  and  by  thyroid  feeding. 

internal    environment,    and    that    sleep    is    the    phase    of 
recharging  the  batteries. 

If  we  accept  this  hypothesis,  that  the  organism  is  an 
electrochemical  mechanism,  in  which  increased  functional 
activity  is  synonymous  with  increased  electric  conductivity, 
then,  since  iodin  and  increased  thyroid  activity  alike  have 
the  power  of  speeding  up  the  organism,  it  would  follow  that 
in  iodism  the  electric  conductivity  of  the  brain  would  be 
increased.  In  the  course  of  a  research  in  our  laboratory, 


THE  FUNCTION  OF  THE  THYROID  23 

which  I  projected  to  test  this  point,  Miss  Hosmer  and  Miss 
Rowland  found  that  the  electric  conductivity  of  the  brains 
of  animals  in  a  state  of  acute  iodism  was  increased  (Fig.  1). 
The  application  of  this  finding  to  the  phenomena  of  myx- 
edema,  on  the  one  hand,  and  of  exophthalmic  goiter,  on 
the  other  hand,  would  seem  to  indicate  that  in  the  former 
condition  there  is  a  state  of  chronic  hypoiodism;  in  the  lat- 
ter, chronic  hyperiodism,  or  as  C.  H.  Mayo  designated 
it,  hyperthyroidism. 

The  validity  of  the  foregoing  findings  is  strengthened 
by  the  work  of  Meyer  in  the  Marine  Laboratory  in  Florida, 
who  found  that  iodin  increased  the  electric  conductivity  of 
water,  in  which  nerve  was  immersed,  at  the  same  rate 
that  it  increased  the  conductivity  of  the  nerve  itself. 

In  view  of  these  findings  it  would  appear  that  if  iodin 
has  the  power  of  increasing  both  function  and  conductivity, 
then  it  should  follow  that  in  ordinary  iodism  the  adrenalin 
sensitization  test  would  be  positive.  In  one  clinical  case 
of  mild  iodiform-poisoning  a  positive  reaction  to  adrenalin 
was  secured;  but  opportunities  for  such  observations  are 
necessarily,  and  fortunately,  rare.  It  then  occurred  to  us 
that  since  in  most  and  perhaps  all  organs  increased  heat  is 
coincident  with  increased  function,  the  measurements  of 
the  actual  temperature  of  the  brain  and  other  organs  under 
varying  degrees  of  activation  might  be  of  value.  We  there- 
fore devised  suitable  copper-constantan  thermocouples  and 
installed  sensitive  galvanometers  whereby  temperature 
variations  could  be  measured  to  one  one-thousandth  of  a 
degree  Centigrade. 

Having  found  that  the  intravenous  injection  of  adrenalin 
produced  a  measurable  increase  in  the  temperature  of  the 
brain,  we  proceeded  to  study  the  effect  of  the  injection  of 
adrenalin  into  iodized  animals.  Two  rabbits  out  of  four  of 


24 


THE    THYROID    GLAND 


approximately  the  same  weight  and  age,  all  of  which  had 
been  kept  for  some  time  under  identical  conditions,  were 
iodized  by  the  intraperitoneal  injection  of  iodoform;  the 
other  two  were  kept  as  controls.  After  the  insertion  of  the 
thermocouple  in  the  brain  an  identical  dose  of  adrenalin 
per  kilo  weight  was  injected  into  each  of  these  rabbits,  the 
temperature  reading  being  continuous  before,  during,  and 
for  a  sufficient  period  after  the  injection.  We  found  that  the 


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Fig.  2. — Comparison  of  the  effects  on  the  temperature  of  the  brain  of  the 
injection  of  adrenalin  in  normal  and  in  iodized  animals. 

adrenalin  caused  a  greater  and  a  more  prompt  increase  in 
temperature  in  the  brain  of  the  iodized  animals  than  in 
the  controls.  This  finding  may  be  offered  as  a  physical 
interpretation  of  the  sensitization  of  the  organism  to  ad- 
renalin in  hyperthyroidism  (Goetsch  test)  (Fig.  2). 

It  would  appear  that  the  study  of  the  thyroid  begins 
and  ends  with  iodin.  Marine  states  that  simple  goiters 
and  the  incidence  of  fetal  adenomata  result  from  a  defi- 
ciency of  iodin  alone.  On  the  other  hand,  goiters  of  the 


THE    FUNCTION    OF   THE    THYROID  25 

exophthalmic  type  are  due  to  hyperiodism — the  hyper- 
secretion  of  thyro-iodin  by  the  thyroid.  The  excessive 
iodism  causes  abnormal  permeability  of  the  cell  membranes. 
Increased  permeability  of  the  cells  means  increased  activity. 
Increased  activity  of  the  cells — increased  metabolism — is 
one  of  the  results  alike  of  iodism  and  of  stimulation. 


A  PHYSICAL  INTERPRETATION  OF  THE  ROLE  OF  THE 
ADRENALS  IN  EXOPHTHALMIC  GOITER 

GEORGE  W.  CHILE 


THAT  the  adrenal  glands  are  powerful  activators  of  the 
brain,  and  that  their  aid  is  promptly  elicited  when  increased 
metabolism — increased  work — is  required,  is  shown  by  the 
fact  that  adrenalin  alone  produces  nearly  all  the  symptoms 
produced  by  the  various  causes  of  increased  energy  trans- 
formation, such  as  emotion,  exertion,  injury,  infection.  That 
is,  adrenalin  causes  increased  metabolism,  increased  thyroid 
activity,  increased  blood-pressure,  increased  pulse,  increased 
respiration,  leukocytosis,  increased  sweating,  dilation  of  the 
pupils,  diversion  of  the  blood  to  the  surface,  lowering  of  the 
threshold  at  the  myoneural  junction.  But  it  is  the  thyro- 
iodin  (thyroxin)  that  sensitizes  the  tissues  to  adrenalin. 
Adrenalin  increases  hyperthyroidism;  hyperthyroidism  in- 
creases adrenalism;  i.  e.,  hyperthyroidism,  iodism,  and  ad- 
renalism  coexist,  each  augmenting  the  other. 

Of  no  less  significance  are  the  facts  that  adrenalin 
causes  hyperchromatism  and  later  chromatolysis  of  the 
brain  cells,  just  as  do  emotion,  injury,  exertion,  infection; 
that  it  causes  an  immediate  increase  in  the  electric  conduc- 
tivity of  the  brain,  and  an  immediate  production  of  heat,  as 
has  been  shown  by  thermocouple  records;  and  that  when  the 
adrenals  are  removed  the  brain  cells  rapidly  degenerate, 
the  animal  rapidly  loses  the  power  to  fabricate  heat,  and 
muscular  and  mental  action,  and  death  usually  follows. 

We  conclude,  therefore,  that  the  brain  is  dependent  on 

27 


28 


THE    THYROID    GLAND 


the  adrenals,  both  for  function  and  for  survival.  The 
adrenals  may  show  enlargement  in  some  chronic  activations, 
such  as  infection,  pregnancy,  rutting  season,  exophthalmic 
goiter.  The  adrenals,  therefore,  must  be  included  among  the 
means  by  which  the  organism  is  activated. 

In  our  measurements   of   the   electric  conductivity  of 
animal  tissues  under  varying  conditions,  we  found  that  ad- 


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Fig.  3. — Early  and  late  effects  of  various  forms  of  stimulation  on  the  electric 
conductivity  of  the  cerebrum. 

renalin  first  increases  the  conductivity  of  the  brain,  and 
that,  as  a  result  of  the  injection  of  excessive  doses  of  ad- 
renalin, the  conductivity  of  the  brain  is  decreased,  as  is  the 
case  in  other  forms  of  stimulation  (Fig.  3,  A).  If  conduc- 
tivity is  related  to  stimulation,  then  an  increase  or  decrease 
in  conductivity  would  be  associated  with  an  increase  or 
decrease  in  function,  i.  e.,  with  activity  or  exhaustion.  Our 
electric  conductivity  observations  have  indicated  that  the 


ROLE  OF  THE  ADRENALS  IN  EXOPHTHALMIC  GOITER    29 

first  effect  of  the  excitants  of  bodily  activity,  such  as  in- 
jury, fright,  toxins,  is  to  increase  the  conductivity  of  the 
brain,  while  in  every  type  of  exhaustion  studied  the  con- 
ductivity of  the  brain  was  decreased  when  the  state  of 
exhaustion  was  established  (Fig.  3) . 

If  the  activation  of  the  brain  is  a  phenomenon  of  electric 
energy,  then  since  electric  energy  depends  upon  oxidation, 
and  oxidation  hi  part  at  least  is  controlled  by  adrenalin,  it 
obviously  follows  that  excessive  adrenalin  would  ultimately 
cause  fatigue  and  decreased  conductivity.  This  may  be  the 
cause  of  the  great  fatigue  which  is  uniformly  seen  in  cases 
of  advanced  hyperthyroidism. 

Both  experimental  and  clinical  phenomena  seem  to 
indicate  that  the  body  is  driven  by  electricity,  which  is 
fabricated  in  the  brain-cells  with  the  aid  of  adrenalin.  But 
we  have  seen  no  evidence  that  adrenalin  covers  more  than 
the  emergencies  of  moments  and  hours,  or  of  days.  Adren- 
alin is  too  evanescent,  too  volatile  to  establish  and  to 
maintain  evenly  an  increased  receptivity,  increased  sensi- 
tiveness to  response,  an  increased  metabolism,  both  basic 
and  adaptive,  day  and  night,  for  weeks  and  months.  We 
assume  that  the  brain  has  no  power  within  itself  to  do  this, 
and  that,  therefore,  prolonged  activation  is  accomplished 
through  the  aid  of  some  other  organ.  If  electricity  is  the 
driving  force  of  the  organism,  and  if  electric  power  is 
increased  by  increasing  the  conductance  of  the  tissues  over 
which  it  passes,  it  would  follow  that  there  must  be  in  the 
body  an  organ  which  is  capable  of  supplying  to  the  blood 
for  weeks  and  months  a  substance  that  is  known  to  increase 
electric  conductance,  the  blood,  in  turn,  supplying  this 
substance  to  the  nervous  system.  This  is  the  role  of  the 
thyroid. 


PARTIAL  HYPERTHYROIDISM 

GEORGE  W.  CRILE 


IN  true  exophthalmic  goiter  the  activity  of  every  tissue 
and  organ  is  speeded.  May  there  be  a  less  inclusive  form 
of  hyperthyroidism?  In  certain  cases  may  some  organs 
and  tissues  be  more  affected  than  other  organs  and  tissues? 
For  a  long  time  it  has  been  noted  that,  following  the  removal 
of  colloid  goiters,  colloid  adenomata  and  adenomata, 
especially  those  of  large  size,  some  patients  have  reported 
an  improvement  in  general  health  beyond  what  one  would 
anticipate  would  result  from  the  mere  removal  of  the 
enlarged  gland.  In  some  cases  the  improvement  has  seemed 
to  pertain  principally  to  the  nervous  system;  in  some  cases 
to  the  heart;  in  some  to  the  blood-pressure.  At  first  it 
appeared  that  this  improvement  must  be  due  to  the  following 
factors:  psychic  relief  from  worry  due  to  the  presence  of 
the  deforming  tumors;  mechanical  relief  from  pressure; 
relief  from  interference  with  the  respiratory  exchange. 
Doubtless  these  factors  are  worthy  of  due  consideration  in 
certain  cases. 

But  increasing  experience  has  demonstrated  that  there 
is  like  improvement  in  cases  in  which  there  has  been  no 
psychic  stress;  no  interference  with  the  circulation  in  the 
venous  trunks ;  no  interference  with  the  respiratory  exchange. 
It  appears,  therefore,  that  the  improvement  in  certain  cases 
must  be  due  to  the  diminution  of  thyroid  activity  following 
partial  thyroidectomy. 

As  has  been  stated  in  the  preceding  section,  the  only 

31 


32  THE   THYROID   GLAND 

proved  function  of  the  thyroid  gland  is  the  fabrication  of 
iodin  into  an  organic  compound  which  exercises  a  basic 
control  over  the  bodily  processes.  In  hyperplastic  goiters 
this  function  is  most  active;  and  Marine  and  Allen  Graham 
have  shown  that  adenomata  also  perform  the  characteristic 
thyroid  function.  Clinical  evidence  of  the  functional  activity 
of  adenomata  is  found  in  the  frequent  development  of 
symptoms  identical  with  those  which  are  characteristic  of 
exophthalmic  goiter,  and  in  the  disappearance  of  these 
symptoms  after  the  removal  of  the  adenoma. 

A  large  gland  showing  no  hyperplasia  may  secrete  too 
much  thyro-iodin  or  thyroxin,  or  one  may  suppose  that  in 
some  cases  some  organ,  such  as  the  heart,  is  abnormally 
responsive  to  the  normal  thyroid  secretion.  In  hyperthy- 
roidism  due  to  hyperactive  adenomata  either  iodin  or  thyroid 
extract  may  cause  an  aggravation  of  the  symptoms. 

In  view  of  these  facts  the  following  questions  arise: 
Are  the  clinical  symptoms  of  so-called  toxic  adenomata 
due  to  a  physical  degeneration  of  the  adenoma  and  there- 
fore to  be  compared  with  the  clinical  symptoms  that  result 
from  the  degeneration  of  fibroid  tumors?  Are  they  due  to 
such  changes  as  are  produced  by  a  chronic  toxemia,  from 
infection  of  the  gall-bladder,  the  teeth,  the  tonsils,  etc.?  Or 
are  they  due  to  the  thyro-iodin  which  is  fabricated  by  the 
adenoma? 

That  the  last  of  these  queries  suggests  the  true  inter- 
pretation appears  to  be  indicated  not  only  by  the  identity 
of  symptoms  referred  to  above  but  also  by  the  fact  that  the 
well-developed  "toxicity"  from  the  "toxic"  goiter  often  pro- 
duces a  sensitization  of  the  organism  to  adrenalin,  identical 
with  that  present  in  cases  of  hyperplastic  goiter  which  are 
associated  with  exophthalmos  and  the  other  characteristic 
symptoms  of  exophthalmic  goiter.  In  fact,  with  the  excep- 


PARTIAL   HYPERTHYROIDISM  33 

tion  of  exophthalmos,  all  the  characteristic  symptoms  of 
true  "exophthalmic  goiter"  may  be  present  in  cases  of 
so-called  "toxic  adenomata,"  i.  e.,  increased  basal  metab- 
olism, tachycardia,  nervousness,  tendency  to  fever,  low 
thresholds,  emaciation,  although  certain  symptoms,  such 
as  increased  appetite,  may  not  be  as  marked  as  in  exoph- 
thalmic goiter. 

In  toxemias  from  the  toxins  of  degeneration  of  other 
tumors,  such  as  fibroid  of  the  uterus,  and  in  chronic  infec- 
tions, as  a  rule,  neither  the  appetite  nor  the  basal  metabo- 
lism is  increased.  Occasionally  one  sees  cases  of  high  blood- 
pressure,  of  myocarditis,  or  of  neurasthenia  in,  which  the 
only  evidence  of  the  thyroid  involvement  is  the  presence  of 
a  goiter.  In  some  of  these  cases  good  results  have  followed 
the  excision  of  the  thyroid  gland.  It  would  appear  that 
adenomata  may  cause  every  grade  of  pathologic  physiology 
progressively  from  myocarditis,  increased  blood-pressure, 
nervousness,  and  increased  metabolism  on  up  to  true 
exophthalmic  goiter.  This  progressive  involvement  of 
bodily  processes,  due  to  adenomata,  is  analogous  to  the 
progressive  effects  of  various  grades  of  infection  from  mild 
oral  sepsis  to  chronic  empyema  of  the  gall-bladder,  acute 
peritonitis,  or  acute  osteomyelitis.  It  would  seem,  there- 
fore, that  the  various  types  of  goiter  should  logically  be 
regarded  as  varying  degrees  of  the  same  or  similar  processes, 
and  that,  certainly  as  far  as  treatment  is  concerned,  no 
differentiation  should  be  made  between  exophthalmic 
goiter  with  hyperplasia  and  the  so-called  "thyrotoxicosis" 
from  adenomata,  or  some  of  the  atypical  forms  of  the 
disease;  that  the  same  regimen  of  management  which 
has  proved  effective  in  the  treatment  of  exophthalmic 
goiter  will  produce  like  results  in  the  treatment  of  the 

so-called    "toxic    adenomata."      It    would    seem    that    the 
3 


34  THE   THYROID   GLAND 

varying  phenomena  which  have  been  called  "toxic  goiter" 
should  be  regarded  as  varying  degrees  of  iodism  or  hyper- 
thyroidism  rather  than  a  toxemia. 

It  is  difficult  to  reach  any  conclusion  on  this  point  which 
is  not  fully  in  accord  with  the  monumental  work  of  Plum- 
mer.  In  any  case,  whatever  one's  opinion,  the  treatment 
and  the  clinical  results  are  identical,  so  that  the  point  of 
view  matters  but  little  after  all. 


DISEASES  AND  PATHOLOGY  OF  THE  THYROID  GLAND 

ALLEN  GRAHAM 


IN  considering  the  variations  from  the  normal  that  occur 
in  the  human  thyroid  gland  it  is  very  important  to  bear  in 
mind  and  differentiate  between  those  changes  that  may  in 
general  be  classed  as  physiologic  and  those  that  are  dis- 
tinctly pathologic.  This  is  all  the  more  necessary  since  the 
changes  of  both  types  may  be  closely  associated  in  the 
same  gland,  and  furthermore,  a  physiologic  alteration  may 
merge  into  one  which  is  distinctly  pathologic,  the  dividing 
line  being  not  always  distinct. 

The  consideration  of  the  various  types  of  changes  in 
the  thyroid  gland  will  be  facilitated  and  rendered  more 
objective  by  the  following  classification,  adapted  from 
Marine,  to  whom  I  wish  to  express  my  indebtedness  for 
much  valuable  information  concerning  the  thyroid.  This 
classification,  although  simple,  at  the  same  time  includes 
all  important  variations  from  the  normal. 

1.  Normal. 

2.  Hypertrophy. 

3.  Hyperplasia. 

4.  Colloid  goiter. 

5.  Exhaustion,  atrophy,  fibrosis. 

Type  A.     Diffuse  colloid  adenomatous  goiter. 
Pure  fetal. 


6.  Adenoma,  benign     _, 

Type  B.     Fetal1  •{  Intermediate. 

[  Colloid. 

7.  Adenoma,  malignant. 

8.  Carcinoma. 

9.  Sarcoma. 

10.  Inflammation. 

1  The  divisions  under  "Fetal  Adenoma"  refer  to  the  degrees  of  differ- 
entiation. 

35 


36  THE   THYROID    GLAND 

In  order  to  save  subsequent  repetition  we  wish  to  dis- 
miss with  only  a  few  words  the  host  of  accidental  and 
complicating  conditions  that  are  so  frequently  present  in 
tumorous  thyroids,  such  as  edema,  myxomatous  and  hyaline 
degeneration,  necrosis,  scars,  hemorrhage,  calcification,  ossi- 
fication, or  cysts.  These  conditions  rarely  occur  in  uncom- 
plicated non-tumorous  thyroids,  and  it  is  almost  equally 
uncommon  to  find  adenomata  or  tumors  of  any  size  without 
the  presence  of  some  or  all  of  them.  These  complications 
are  not  peculiar  to  thyroids  and  have  no  other  significance 
than  has  their  occurrence  in  any  other  tissue  of  the  body. 

Thyroid  cysts  are  of  two  kinds:  First,  simple  colloid 
retention  cysts,  which  bear  no  relation  to  tumors  of  the 
thyroid,  distended  thyroid  follicles  or  a  coalescence  of 
follicles;  and  second,  cysts  resulting  from  hemorrhage  into 
existing  adenomata  or  other  tumors,  or  their  degeneration 
and  necrosis.  This  second  group  includes  a  great  majority  of 
cysts  of  the  thyroid. 

As  for  lymphoid  tissue,  we  have  no  very  satisfactory 
explanation  of  its  presence  or  significance,  but  it  is  fre- 
quently found  in  this  locality  and  generally  in  those  patients 
who  show  other  evidence  of  lymphoid  overgrowth,  such  as 
adenoids,  hypertrophy  of  the  tonsils,  and  enlargement  of 
the  superficial  lymph-nodes.  It  occurs  as  diffuse  lymphoid 
infiltration  and  well-organized  lymphoid  follicles  with  ger- 
minal centers. 

No  further  reference  to  these  accidents  and  complica- 
tions will  be  made. 

NORMAL  THYROID   (Fig.  4,  A) 

The  normal  thyroid  is  a  uniform  uncomplicated  non- 
tumorous  gland  with  two  lateral  lobes  connected  by  an 
isthmus.  The  cut  surface  is  uniformly  lobulated  through- 


DISEASES   AND    PATHOLOGY    OF   THYROID    GLAND  37 


Fig.  4. — Hypertrophy  and  hyperplasia  of  the  thyroid  gland. 


38  THE   THYROID    GLAND 

out;  colloid  material  is  present  throughout;  its  weight 
varies  between  25  and  40  grams;  the  iodin  content  averages 
about  3  mgm.  per  gram  of  the  dried  gland. 

Histologic  examination  shows  follicles  of  fairly  uniform 
size  and  shape,  which  are  well  filled  with  deeply  and  uni- 
formly staining  colloid  completely  filling  the  acini  and 
resting  against  a  single  layer  of  cuboidal  epithelial  cells. 

HYPERTROPHY  AND  HYPERPLASIA  (Fig.  4,  B-H) 

These  terms  are  used  in  their  strict  pathologic  sense  and 
are  considered  together  because  they  are  frequently  asso- 
ciated in  the  same  gland,  and  when  they  so  occur  it  is  not 
always  possible  to  distinguish  one  from  the  other.  In  this 
discussion  no  attempt  will  be  made  to  draw  fine  distinctions 
nor  to  dissociate  these  commonly  associated  conditions. 

Under  such  influences  as  induce  thyroid  enlargement 
in  man,  regardless  of  their  nature  or  cause,  the  gland 
undergoes  certain  changes  depending  upon  the  intensity 
and  duration  of  the  exciting  cause.  Whatever  the  cause, 
so  far  as  non-tumorous  thyroids  are  concerned,  there  is  a 
difference  in  the  degree,  but  not  in  the  character  of  the 
end-result. 

In  developing  goiters,  either  simple  or  exophthalmic,  the 
thyroid  enlarges;  the  vascularity  increases;  the  gland 
becomes  softer;  the  iodin  and  colloid  contents  diminish; 
the  follicles  become  larger,  and  may  be  variable  in  size  and 
outline;  the  epithelial  cells  increase  in  size.  These  changes 
constitute  simple  hypertrophy. 

If  the  exciting  cause  continues  to  operate,  the  changes 
listed  above  increase  in  degree;  and  to  them  may  be  added 
actual  proliferation  of  the  epithelium  in  the  follicles,  or  the 
formation  of  new  follicles,  or  both,  and  with  this,  infoldings, 
plications,  and  papillary  projections  of  the  wall  into  the 


DISEASES    AND    PATHOLOGY    OF    THYROID    GLAND  39 

lumen  of  the  follicles.  These  changes  constitute  hyper- 
plasia.  It  is  almost  inconceivable  that  the  thyroid  can 
jump  from  its  normal  state  into  a  well-marked  hyperplasia 
without  there  having  been  some  degree  of  simple  hyper- 
trophy, unless  the  hyperplasia  is  a  manifestation  of  malig- 
nant new  growth. 

Should  the  exciting  cause  cease  to  operate  after  the 
gland  has  passed  through  the  stages  of  hypertrophy  and 
hyperplasia,  the  gland  will  tend  to  undergo  involution 
toward  recovery  (Fig.  4,  F-H).  When  the  involution  or 
recovery  is  complete  the  gland  becomes  a  colloid  goiter, 
according  to  our  conception. 

COLLOID  GOITER  (Fig.  4,  H,  I) 

In  the  reversion  from  hyperplasia  or  hypertrophy  to  the 
colloid  or  resting  state  the  gland  generally  decreases  in  size, 
becomes  firmer,  its  vascularity  decreases,  the  iodin  and 
colloid  contents  increase,  the  follicles  generally  remain 
somewhat  larger  and  not  so  uniform  in  size  and  shape  as 
in  the  normal  gland.  The  colloid  is  apt  to  show  vacuoles 
and  desquamated  cells.  The  epithelial  cells  lining  the 
follicles  become  cuboidal  or  even  may  be  flatter  than 
normal.  The  above  applies  to  those  glands  that  have 
undergone  hypertrophy  and  hyperplasia  for  the  first  time. 
After  involution  they  closely  resemble  the  normal  thyroid. 
In  the  case  of  glands  that  have  passed  through  the  cycle  a 
number  of  times  or  of  those  in  which  the  hyperplasia  is  of 
long  standing,  the  appearance  after  involution  will  not  so 
closely  resemble  the  normal  thyroid. 

As  far  as  is  known,  a  colloid  goiter  has  the  same  physio- 
logic and  biologic  capabilities  as  the  normal  gland,  and  it 
reacts  to  a  sufficiency  or  an  insufficiency  of  iodin  in  the 
same  way  and  almost  if  not  quite  to  the  same  degree  as 


40  THE   THYROID    GLAND 

does  the  normal  thyroid.  The  chief  differences  between  a 
normal  gland  and  a  colloid  goiter  are  the  following:  The 
colloid  goiter  has  been  hypertrophic  or  hyperplastic,  or 
both,  and  has  recovered;  it  is  usually  larger  than  the  normal 
gland;  the  follicles  show  greater  variations  in  size  and 
shape;  the  lining  cells  are  more  apt  to  be  flattened;  the 
stroma  is  increased;  and  finally,  we  do  not  classify  as 
strictly  normal  any  thyroid  in  which  there  is  an  adenoma. 
We  regard  an  adenoma  in  itself  as  an  indication  of  previous 
thyroid  enlargement. 

EXHAUSTION,  ATROPHY,  AND  FIBROSIS  (Fig.  4,  E) 

After  the  gland  has  become  hypertrophic,  hyperplastic, 
or  both,  if  the  influences  or  causes  that  induce  overgrowth 
continue  to  operate  long  enough  or  with  sufficient  intensity, 
the  changes  characteristic  of  hypertrophy  and  hyperplasia 
will  progress  to  the  point  of  breakdown  or  exhaustion  of 
the  thyroid  parenchyma.  At  and  beyond  this  point  the 
epithelium  is  incapable  of  physiologic  recovery.  The  per- 
centage of  gland  tissue  destroyed  in  this  manner  is,  of 
course,  variable,  and  depends  upon  the  duration  and 
intensity  of  the  exciting  cause  or  causes.  Destruction  of 
the  entire  gland  is  incompatible  with  life;  a  lesser  degree 
of  degeneration  produces  the  clinical  condition — myxedema. 

Following  this  exhaustion  and  destruction  of  the  paren- 
chyma there  is  atrophy  and  fibrosis.  Indeed,  the  fibrosis 
may  have  its  origin  in  the  repeated  cycles  of  thyroid  over- 
growth and  involution. 

Under  the  preceding  five  headings  we  have  considered 
only  non-tumorous  thyroid  tissue;  consideration  of  the 
tumorous  conditions  follows.  Suffice  it  to  say  here  that 
any  kind  of  an  adenoma  may  be  present  in  a  gland  in  any 
stage  of  hypertrophy,  of  hyperplasia,  of  colloid  goiter,  or 
of  atrophy,  but  does  not  occur  in  normal  glands. 


DISEASES   AND    PATHOLOGY   OF   THYROID    GLAND  41 

ADENOMA,  BENIGN 

Clinically  and  pathologically  there  are  two  types  of 
adenomatous  thyroid  which,  for  the  sake  of  convenience, 
we  shall  designate  as  Type  A  and  Type  B. 

Type  A.  Diffuse  Colloid  Adenomatous  Goiter  (Fig.  5, 
A). — It  may  be  said  at  the  outset  that  it  is  more  difficult 
to  explain  satisfactorily  the  origin  and  nature  of  this  type 
of  goiter  than  of  any  other  type  of  pathologic  change  of  the 
thyroid  gland.  Two  possibilities  suggest  themselves,  neither 
of  which  is  entirely  satisfactory.  Does  this  change  originate 
in  a  fetal  adenoma  of  possibly  the  more  highly  differentiated 
type?  If  so,  it  would  be  very  difficult  to  explain  the  facts 
that  this  type  of  goiter  is  invariably  present  in  both  lateral 
lobes;  that  the  individual  nodules  are  made  up  of  well- 
differentiated  follicles  rich  in  colloid;  that  the  individual 
nodules  do  not  make  tumors  of  any  considerable  size;  that 
the  capsules  are  thin;  that  the  goiter  rarely  if  ever  becomes 
malignant.  In  all  these  respects  fetal  adenoma  presents  a 
directly  opposed  picture.  Does  this  type  of  goiter  originate 
in  old,  long-standing  colloid  goiters?  If  so,  it  is  difficult  to 
understand  why  the  change  most  frequently  arises  in  the 
regions  next  the  trachea  and  seems  to  proceed  toward  the 
outer  capsule  of  the  gland.  On  the  other  hand,  the  individual 
nodules  are  not  densely  encapsulated  and  histologically  the 
follicles  resemble  those  of  the  normal  thyroid  and  of  colloid 
goiter,  except  for  one  important  difference,  namely,  that  in 
the  diffuse  colloid  adenomatous  goiter,  regardless  of  size, 
the  individual  masses  are  never  lobulated  structures. 

Type  B.  Fetal  adenoma,  with  its  various  stages  of 
growth  and  differentiation  (Fig.  5,  B-I). 

This  type  of  adenoma  has  its  origin  in  the  so-called 
Wolfler's  rests,  embryonal  remnants  left  over  from  the 
developmental  period  of  the  thyroid.  This  type  is  more 


42 


THE   THYROID   GLAND 


Fig.  5. — Fetal  adenoma  in  various  stages. 


DISEASES   AND    PATHOLOGY    OF    THYROID    GLAND  43 

definitely  a  tumor  than  Type  A.  The  fetal  adenoma  con- 
sists of  a  circumscribed,  well-encapsulated  mass  of  non- 
lobulated  thyroid  tissue  made  up  of  follicles,  the  histologic 
appearance  of  which,  except  for  complications,  depends 
upon  the  stage  of  growth  and  differentiation  which  they 
have  attained  at  the  time  of  examination.  The  Wolfler 
rests  laid  down  in  intra-uterine  life  may  be  present  in  one 
or  both  lobes  and  in  any  part  of  the  lobe,  as  single  or  multiple 
small  clumps  of  embryonal  cells.  In  the  early  stages  they 
have  no  capsule,  are  not  arranged  in  follicles,  contain  no 
colloid  or  iodin.  They  may  remain  in  this  condition 
throughout  life  and  never  grow  or  differentiate,  or  they 
may  start  growing  at  any  time  of  life.  In  their  growth  there 
is  always  the  tendency  to  become  more  differentiated,  that 
is,  to  develop  definite  well-formed  follicles  which  increase 
in  size,  accumulate  colloid  and  iodin,  and  are  lined  by  a 
single  layer  of  cuboidal  epithelial  cells,  so  that  in  an  advanced 
stage  a  particular  follicle  may  look  just  like  a  normal  thyroid 
follicle  of  the  same  size.  In  the  same  gland  there  may  be 
present  a  pure  fetal  adenoma  showing  little  or  no  differ- 
entiation— a  solid  grayish  opaque  cellular  mass  with  little 
or  no  colloid  or  iodin  and  having  very  small  follicles,  and 
next  to  it  a  fully  differentiated  fetal  adenoma  rich  in  colloid 
and  iodin  and  having  large  follicles  resembling  those  of  the 
normal  thyroid.  The  histologic  and  gross  appearances  of 
the  two  are  very  different,  yet  there  seems  no  doubt  that 
they  represent  different  stages  of  the  same  process.  Between 
these  two  extremes  all  gradations  are  frequently  encoun- 
tered in  the  surgical  clinic. 

ADENOMA,  MALIGNANT  (Fig.  6,  A-H) 

This  title  is  used  in  our  classification  to  include  the 
numerous  thyroid  tumors,  regarding  which  at  the  time  of 


44 


THE    THYROID    GLAND 


Fig.  6. — Malignant  adenoma. 


DISEASES   AND    PATHOLOGY    OF   THYROID    GLAND  45 

their  removal  in  the  clinic  the  pathologist  cannot  state 
definitely  whether  or  not  they  are  malignant.  There  is  a 
firm  and  increasing  conviction  born  of  past  experience  and 
increasing  yearly  that  these  tumors  represent  a  stage  in 
progress  from  the  certainly  benign  to  the  certainly  malig- 
nant. They  correspond  to  what  more  recently  in  the 
pathology  of  other  tissues  and  organs  has  been  called  the 
precancerous  or  premalignant  lesion.  The  subsequent 
history  of  many  of  these  cases  has  proved  the  doubtful 
tumor  to  be  malignant,  while,  on  the  other  hand,  some 
patients  have  lived  for  years  with  no  evidence  of  recurrence 
or  metastasis.  The  prognosis  depends  on  whether  these 
doubtful  lesions  are  removed  early  or  late  in  this  pre- 
malignant stage  and  on  whether  or  not  the  adenoma  was 
completely  removed  without  rupture.  Practically  all  these 
tumors  have  their  origin  in  fetal  adenomata,  as  in  this 
clinic  there  has  been  no  instance  in  which  this  type  of 
lesion  had  as  its  sole  origin  a  diffuse  colloid  adenomatous 
goiter.  Moreover,  one  may  make  a  series  as  one  wishes  of 
the  various  steps,  stages,  and  degrees  whereby  the  innocent, 
certainly  benign,  pure  fetal  adenoma  is  transformed  both 
grossly  and  microscopically  to  the  undoubted  cancer,  with 
every  evidence  of  malignancy.  From  our  experience  it 
appears  that  malignant  adenomata  arise  most  frequently 
from  the  less  differentiated  fetal  adenomata,  and  that  the 
more  the  fetal  adenoma  approaches  maturity  or  full  differ- 
entiation, the  less  likely  is  it  to  become  malignant. 

CARCINOMA   (Fig.  6,  I  and  7,  A) 

From  adenomata  of  the  type  we  have  just  discussed  it 
is  but  a  step  to  malignancy  with  all  the  usual  evidences 
thereof.  Fully  95  per  cent,  of  malignant  growths  in  the 
thyroid  are  carcinomata,  and  fully  90  per  cent,  of  these 


46 


THE   THYROID   GLAND 


Fig.  7. — Various  malignant  types  of  thyroid  disease. 


DISEASES   AND   PATHOLOGY   OF   THYROID   GLAND  47 

develop  from  fetal  adenomata,  passing  through  the  stage 
which  we  have  denominated  "malignant  adenoma."  Con- 
sequently, fetal  adenoma,  and  especially  malignant  adenoma, 
becomes  one  of  the  most  important  surgical  lesions  of  the 
thyroid.  It  is  beyond  the  scope  of  this  article  to  undertake 
a  minute  description  of  the  gross  and  microscopic  anatomy 
of  these  tumors. 

Aside  from  this  main  group  of  thyroid  malignancies 
there  are  a  small  number  of  carcinomata  which  are  not 
dependent  upon  adenomata  for  their  origin.  In  this  group 
papillary  carcinoma  is  most  frequently  encountered.  This 
seems  to  originate  in  the  papillomatous  processes  found  in 
non-adenomatous  as  well  as  in  adenomatous  (not  neces- 
sarily fetal)  thyroids. 

In  addition  to  the  above  there  are  a  few  carcinomata 
which  cannot  be  satisfactorily  included  in  either  classifica- 
tion whose  exact  origin  and  nature  remains  in  doubt.  It  is 
interesting  to  note  in  this  connection  that  occasionally  a 
tumorous  thyroid  is  encountered  in  regard  to  whose  char- 
acter pathologists  will  disagree  as  to  whether  it  is  a  carci- 
noma, endothelioma,  or  sarcoma. 

SARCOMA  (Fig.  7,  B-D) 

Sarcomata  represent  less  than  5  per  cent,  of  the  malig- 
nant tumors  of  the  thyroid.  Sarcomata  of  the  thyroid  do 
not  differ  from  sarcomata  in  other  organs  or  tissues,  the  most 
frequent  types  being  the  round  and  the  spindle-cell  sarcoma. 
Occasionally  one  meets  with  curious  combinations  of  round, 
spindle-,  and  giant-cell  tumors.  Sometimes  both  a  sarcoma 
and  a  carcinoma  may  be  present  in  the  same  gland.  Of 
course,  primary  lymphosarcomata  are  found  whose  origin 
is  probably  in  the  lymphoid  tissue  which  is  so  commonly 
present  in  thyroids  in  this  locality  (Fig.  7,  E,  F). 


48  THE    THYROID    GLAND 

INFLAMMATIONS 

Any  kind  of  infectious  and  inflammatory  process  may 
occur  in  the  thyroid,  particularly  acute  pyogenic  abscess; 
more  or  less  diffuse  acute  inflammatory  reactions  around 
adenomata,  especially  when  they  are  hemorrhagic,  degen- 
erating or  cystic;  syphilis,  and  tuberculosis.  Tuberculosis 
most  commonly  occurs  in  the  form  of  miliary  tubercles, 
although  conglomerate  and  caseous  areas  are  sometimes 
seen.  The  above-mentioned  inflammatory  lesions  may 
occur  in  any  type  of  thyroid  (Fig.  7,  G,  H). 

Of  particular  interest  is  a  type  of  chronic  inflammatory 
process  that  has  been  termed  "ligneous  thyroiditis"  (Fig. 
7,  I).  This  generally  occurs  in  adenomatous  thyroids, 
and  before  operation  is  usually  diagnosed  as  malignant  on 
account  of  its  firmness  and  immobility,  due  to  adhesions 
to  muscle  and  other  cervical  structures.  In  considering 
clinical  cases  showing  such  signs  it  is  well  to  remember  this 
"ligneous  thyroiditis,"  as  the  patients  in  whom  it  occurs 
can  be  greatly  and  permanently  benefited  by  operation 
and  need  not  be  doomed  by  the  diagnosis  of  "inoperable 
malignant  tumor." 


CARDIAC  DISTURBANCES  ASSOCIATED  WITH  DISEASE 
OF  THE  THYROID  GLAND 

JOHN  PHILLIPS 


INTRODUCTION 

AMONG  the  striking  features  associated  with  disease  of 
the  thyroid  gland  Parry,  in  his  original  description  in  1815, 
emphasized  the  importance  of  cardiac  disturbances.  The 
first  case  of  this  character  described  by  him  was  that  of  a 
married  woman,  aged  thirty-seven,  whom  he  saw  in  1786. 
Six  years  previously  she  caught  cold  after  childbirth  and 
for  a  month  suffered  from  acute  rheumatic  fever.  Following 
this  she  had  tachycardia  and  irregularity  of  the  heart,  with 
two  or  three  nocturnal  attacks  of  difficult  breathing,  accom- 
panied by  the  spitting  of  a  small  quantity  of  blood.  Three 
months  after  labor,  while  nursing  her  child,  a  lump  the  size 
of  a  walnut  appeared  on  the  right  side  of  her  neck.  This 
continued  to  enlarge  until  the  period  when  Parry  saw  her, 
when  it  had  reached  an  enormous  size,  occupying  both 
sides  of  the  neck  and  projecting  beyond  the  jaw.  This 
proved  to  be  an  enlargement  of  the  thyroid  gland.  The 
carotid  arteries  were  greatly  distended  and  the  eyes  pro- 
truded from  their  sockets.  The  patient  subsequently  devel- 
oped general  anasarca  and  died  from  cardiac  failure.  The 
primary  etiologic  factor  of  the  cardiac  lesion  in  this  case 
in  all  probability  was  the  acute  rheumatic  fever,  but, 
unquestionably,  the  goiter  played  an  important  part  in  the 
later  manifestations.  Graves  (1835),  Basedow  (1845), 
Stokes  (1854),  and  Trousseau  (1856)  also  mention  the 
cardiac  features  of  disease  of  the  thyroid  gland. 

In  colloid  goiter  or  in  cases  of  adenomatous  enlargement 

4  49 


50  THE   THYROID   GLAND 

of  the  thyroid  the  contents  of  the  superior  mediastinum  may 
be  encroached  upon,  causing  disturbances  of  the  lungs  and 
heart.  Pressure  on  the  trachea  may  prevent  adequate 
filling  of  the  lungs,  this  producing  emphysema  with  deficient 
aeration  of  the  blood  and  subsequent  myocardial  weakness. 
Pressure  on  the  sympathetic  ganglia  on  one  or  both  sides 
of  the  neck  may  stimulate  the  accelerator  nerves  and  cause 
a  chronic  tachycardia. 

THE  RELATION  OF  ADENOMATA  TO  CARDIAC  DISTURBANCES 

I  would  particularly  like  to  call  attention  to  marked 
cardiac  disturbances  which  appear  in  middle  life  or  later 
in  patients  who  for  many  years  have  had  an  adenomatous 
enlargement  of  the  thyroid  gland.  These  cardiac  mani- 
festations may  completely  overshadow  all  the  other  toxic 
symptoms  from  the  goiter,  which,  in  fact,  may  be  so  slight 
as  to  make  it  appear  that  the  goiter  plays  little  or  no  part 
in  the  disease.  In  these  cases  the  cardiac  phenomena  may 
resemble  those  of  the  ordinary  case  of  toxic  goiter,  i.  e., 
continuous  elevation  of  the  pulse-rate  with  occasional 
attacks  of  intense  tachycardia  on  awakening  or  brought 
on  by  emotion,  excitement,  exercise.  These  attacks  usually 
differ  from  the  ordinary  attacks  of  paroxysmal  tachycardia 
in  that  the  slowing  of  the  pulse-rate  occurs  gradually  instead 
of  abruptly,  although  occasionally  there  is  a  true  paroxysmal 
tachycardia,  as  in  the  following  case: 

A  woman  aged  forty  came  under  observation  in  June, 
1911,  with  symptoms  of  exhaustion,  weakness,  palpitation 
of  the  heart,  and  a  loss  of  twenty  pounds  in  weight.  She 
had  marked  exophthalmos  \vith  a  positive  von  Graefe's  and 
Stellwag's  sign  in  both  eyes.  Her  thyroid  was  enlarged,  the 
enlargement  being  greater  on  the  right  side  than  on  the  left, 
and  in  the  right  lobe  could  be  felt  a  nodule  the  size  of  an 


DISEASE    OF   THYROID,    ASSOCIATED   DISTURBANCES       51 

English  walnut.  A  persistent  fine  tremor  of  the  hands  was 
present.  The  heart  showed  slight  enlargement  of  the  left 
ventricle  and  the  apex-beat  was  very  forcible  and  diffuse. 
The  heart  sounds  were  very  loud,  but  were  unaccompanied 
by  murmurs.  The  cardiac  rate  varied  from  140  to  160 
beats  per  minute;  the  systolic  blood-pressure  was  140,  the 
diastolic  60.  Nothing  of  importance  was  disclosed  in  the 
remainder  of  the  physical  examination.  As  the  result  of 
prolonged  rest  in  bed  for  three  months,  the  use  of  warm 
baths,  and  the  occasional  administration  of  bromid  to 
insure  rest  the  patient  gained  fifteen  pounds  in  weight  and 
her  average  pulse-rate  became  96  per  minute.  Since  then,  by 
living  a  life  free  from  physical  overstrain  or  mental  worry, 
she  has  been  able  to  attend  to  her  household  duties.  In 
June,  1917,  she  had  an  attack  of  paroxysmal  tachycardia 
lasting  forty-five  minutes,  the  heart  abruptly  increasing  its 
rate  to  180  per  minute,  and  ceasing  just  as  abruptly  at  the 
termination  of  the  attack.  She  has  had  two  similar  attacks 
since  then,  one  lasting  thirty  minutes  and  the  other  one  hour. 

Bamberger1  in  1910  reported  three  cases  of  paroxysmal 
tachycardia  associated  with  goiter  and  collected  twenty-one 
cases  from  the  literature.  He  mentions  the  fact  that  in 
some  of  the  patients  an  irregularity  of  the  heart  was  present. 

One  of  my  patients  had  auricular  fibrillation  at  the  time 
I  first  saw  her  and  later  had  attacks  of  paroxysmal  tachy- 
cardia. This  patient,  a  woman  aged  forty-seven,  was  seen 
first  in  November,  1913.  She  complained  that  for  the 
past  four  months  she  had  had  palpitation  of  the  heart, 
vomiting,  shortness  of  breath,  and  swelling  of  the  feet. 
She  had  had  a  goiter  for  the  past  thirty  years  and  recently 
had  noticed  that  her  hair  was  falling  out,  and  that  there 
was  also  a  gradual  disappearance  of  the  hair  from  the 

1  Bamberger,  Deutsche  med.  Wochenschrift,  1910,  xxxv,  1403. 


52  THE    THYROID   GLAND 

axillae  and  pubes.  Her  eyes  were  prominent  and  she  had  a 
positive  Stell  wag's  and  von  Graefe's  sign.  Her  thyroid 
was  enlarged  and  nodular,  the  right  side  being  larger  than 
the  left.  The  cardiac  sounds  were  irregular  both  in  force 
and  rhythm,  the  heart  rate  was  174,  while  that  of  the  pulse 
was  120.  The  liver  was  enlarged  to  6  cm.  below  the  costal 
border  and  there  was  a  small  amount  of  free  fluid  in  the 
abdominal  cavity.  There  was  quite  marked  edema  of  the 
lower  extremities,  while  the  hands  showed  no  edema,  but 
there  was  a  fine  tremor  of  the  extended  fingers.  The  urine 
showed  a  trace  of  albumin  and  a  few  hyaline  and  granular 
casts.  The  diagnosis  was  adenoma  of  the  thyroid  gland  with 
toxic  symptoms,  chronic  myocarditis,  auricular  fibrillation, 
and  cardiac  decompensation.  With  limitation  of  the  total 
daily  quantity  of  fluids,  restriction  of  salt  in  the  diet  and 
the  administration  of  bromids  and  digitalis,  the  edema 
disappeared,  the  pulse-rate  dropped  to  100  per  minute  and 
became  regular,  and  the  vomiting  ceased.  Throughout  the 
next  year,  while  the  patient  was  under  observation,  there 
were  periods  of  temporary  improvement,  but  a  lasting 
cardiac  compensation  was  never  fully  established.  During 
this  time  she  had  four  attacks  of  paroxysmal  tachycardia 
lasting  from  thirty  minutes  to  thirty-six  hours,  the  cardiac 
rate  varying  from  180  to  200.  Both  the  onset  and  the 
termination  of  these  attacks  were  abrupt.  On  December  21, 
1914,  Dr.  Crile  removed  the  left,  median,  and  one-half  of 
the  right  lobe  of  the  thyroid.  These  showed  numerous 
adenomatous  masses  with  varying  grades  of  degenerative 
changes.  After  the  operation  the  patient  gradually  im- 
proved, cardiac  compensation  became  well  established,  and 
when  last  heard  from  three  years  later  she  was  able  to  do 
many  of  the  lighter  duties  about  her  home.  There  was  no 
return  of  the  attacks  of  paroxysmal  tachycardia. 


DISEASE    OF   THYROID,    ASSOCIATED   DISTURBANCES        53 

The  occurrence  of  other  forms  of  cardiac  disturbance  in 
cases  of  goiter  have  been  described,  such  as  sinus  arhythmia, 
premature  contractions,  heart-block,  auricular  flutter,  and 
attacks  of  angina.  Krumbhaar,1  in  an  electrocardiographic 
study  of  fifty-one  cases  of  toxic  goiter,  found  sinus  arhyth- 
mia in  four  cases;  ventricular  extrasystoles  in  three  cases; 
auricular  fibrillation  in  three  cases;  auricular  flutter  in  one 
case;  delayed  conductivity  in  two  cases.  In  two  of  the 
cases  of  auricular  fibrillation  and  in  the  case  of  auricular 
flutter  the  disturbance  remained  constant  for  several  years. 
In  the  other  case  of  fibrillation  the  disturbance  was  tran- 
sient, disappearing  coincidently  with  the  improvement  that 
followed  medical  treatment. 

The  following  case  illustrates  the  association  of  attacks 
of  angina  with  the  presence  of  a  goiter  showing  com- 
paratively mild  symptoms:  An  unmarried  woman,  aged 
fifty-six,  was  seen  first  on  June  15,  1912.  She  complained 
of  feeling  nervous  and  sleepless,  of  increased  lacrimation, 
and  that  her  ears  felt  "as  if  a  lid  had  closed  down."  She 
had  suffered  a  severe  shock  one  year  previously  because  of 
the  sudden  death  of  her  brother.  During  the  past  year  she 
had  lost  twenty  pounds  in  weight.  The  eyes  showed  marked 
exophthalmos  and  on  both  sides  there  was  a  positive  Stell- 
wag's  and  von  Graefe's  sign.  The  median  and  right  lobes 
of  the  thyroid  were  enlarged  and  a  loud  systolic  murmur 
and  venous  hum  were  audible  on  auscultation  over  the 
thyroid.  The  heart  was  slightly  enlarged  to  the  left  and  the 
pulse-rate  was  104;  the  systolic  blood-pressure  was  140, 
diastolic  80.  There  was  a  marked  fine  tremor  of  the  out- 
stretched fingers.  As  the  result  of  rest  in  bed  for  a  period 
of  three  weeks  the  patient's  condition  was  considerably 
improved  and  the  pulse-rate  dropped  to  80.  She  spent 

1  Krumbhaar,  E.  B.,  Electrocardiographic  Observations  in  Toxic  Goiter, 
Amer.  Jour.  Med.  Sci.,  1918,  civ,  175. 


54  THE   THYROID   GLAND 

two  months  at  the  seashore,  and  during  the  latter  part  of 
her  stay  there  she  began  to  have  attacks  of  precordial  pain, 
which  was  also  referred  to  the  left  shoulder  and  down  the 
inner  side  of  the  left  arm.  After  she  returned  home  she  was 
seen  during  a  number  of  these  attacks,  during  which  time 
her  systolic  blood-pressure  averaged  180,  her  diastolic  100. 
She  obtained  considerable  relief  from  the  pain  by  taking 
nitroglycerin.  As  the  anginal  attacks  kept  recurring  and 
she  seemed  to  be  making  no  progress  toward  recovery,  on 
December  1,  1912,  Dr.  Crile  removed  the  right  lobe  of  the 
thyroid  and  ligated  the  left  superior  thyroid  artery.  Fol- 
lowing the  operation  the  patient  had  no  return  of  the 
anginal  attacks,  in  three  months  her  weight  had  increased 
from  90  to  109  pounds,  and  her  systolic  blood-pressure  had 
dropped  to  140,  the  diastolic  to  90,  remaining  at  this  level. 
At  the  present  time,  seven  years  later,  she  is  enjoying  good 
health  and  leading  a  busy  life. 

The  blood-pressure  in  toxic  goiter  resembles  that  seen 
in  cases  of  aortic  regurgitation,  viz.,  an  increased  systolic 
pressure  with  a  low  diastolic,  the  pulse  pressure  being 
increased  above  the  normal  limit.  Studies  of  the  variations 
in  blood-pressure  in  goiter  cases  have  been  made  by  Taussig1 
and  Plummer.2  The  latter  author  found  that  27  per  cent, 
of  patients  over  forty  years  of  age  who  had  non-hyperplastic 
goiter  had  a  systolic  blood-pressure  above  160.  It  is  quite 
conceivable  that  a  relatively  slight  overstimulation  of  the 
vasomotor  mechanism  from  overactivity  of  the  thyroid  or 
from  perverted  secretion,  if  it  persists  over  a  long  period  of 
years,  may  lead  to  an  elevation  of  blood-pressure  or  to 
permanent  myocardial  damage,  which  is  manifested  by 
auricular  fibrillation,  by  paroxysmal  tachycardia,  or  in 
some  instances  by  cardiac  decompensation. 

1  Taussig,  A.  E.,  Tr.  Assn.  Amer.  Phys.,  1916,  xxxi,  121. 

2  Plummer,  H.  S.,  Tr.  Assn.  Amer.  Phys.,  1915,  xxx,  450. 


THE  RELATION  BETWEEN  DISEASES  OF  THE  THYROID 
GLAND  AND  LARYNGEAL  FUNCTION 

JUSTIN  M.  WAUGH 


THE  fact  that  in  cases  of  thyroid  disease  the  function 
of  the  larynx  may  be  impaired  to  a  greater  or  less  degree  is 
now  generally  recognized.  In  general,  physicians  have 
considered  that  this  impairment  of  laryngeal  function  is 
always  the  result  of  surgical  trauma  of  the  recurrent  laryn- 
geal nerve.  We  wish,  therefore,  especially  to  call  attention 
to  cases  in  which  the  laryngeal  impairment  results  from  the 
growth  of  the  goiter  itself  and  is  in  no  way  dependent  upon 
the  surgical  treatment.  A  systematic  study  of  these  cases 
has  been  undertaken  at  the  Cleveland  Clinic  to  the  advan- 
tage alike  of  the  surgeon  and  of  the  patient. 

In  the  past  the  surgeon  has  not  worked  in  sufficiently 
close  co-operation  with  the  laryngologist  in  either  the  pre- 
operative  or  postoperative  study  of  patients  with  thyroid 
diseases.  It  follows  that  the  surgeon  has  judged  his  results, 
as  far  as  the  larynx  is  concerned,  entirely  upon  the  patient's 
ability  to  use  the  voice  without  learning  by  actual  observa- 
tion of  the  movement  and  extent  of  excursion  of  the  vocal 
cords  whether  or  not  they  have  been  impaired. 

In  fact,  many  physicians  think  of  the  larynx  only  in 
its  connection  with  voice  production,  which  they  regard  as 
the  one  essential  index  to  the.  integrity  of  the  larynx  rather 
than  actual  knowledge  of  its  anatomic  and  physiologic 
condition.  They  forget  that  the  most  important  function 
of  the  larynx  is  concerned  with  the  respiration,  and  as  this 
is  one  of  the  automatic  processes  of  the  body  and  its  proper 
performance  depends  upon  the  operation  of  one  of  the  most 

55 


56  THE    THYROID   GLAND 

delicately  balanced  mechanisms  in  the  organism,  any  inter- 
ference with  this  function,  either  by  a  pathologic  growth  of 
the  thyroid  or  as  the  result  of  surgery,  is  obviously  of 
greater  importance  than  any  interference  with  voice 
production. 

The  recurrent  laryngeal  nerves  carry  two  distinct  groups 
of  fibers,  one  the  abductor  group  which  controls  that  func- 
tion of  the  larynx  which  is  associated  with  respiration,  and 
the  other  the  adductor  group  which  supplies  the  voluntary 
muscles  of  the  larynx  and,  therefore,  is  associated  with  the 
function  of  voice  production.  Careful  investigations  by 
both  anatomists  and  pathologists  show  that  about  three 
times  as  many  fibers  are  concerned  in  the  performance  of 
the  adductor  function  of  the  larynx  as  in  the  abductor 
function.  That  the  abductor  function  is  much  more  easily 
impaired,  either  by  pressure  or  by  trauma,  is  beyond  ques- 
tion, and  in  our  opinion  this  cannot  be  wholly  accounted  for 
by  the  numerical  relationship  between  the  two  bundles  of 
fibers.  Undoubtedly  the  abductor  mechanism  which  is 
concerned  with  the  automatic  function  of  respiration  is 
much  more  delicately  arranged  than  the  mechanism  which 
is  concerned  with  the  voluntary  function  of  voice  produc- 
tion. 

The  exact  cause  of  the  weakening  or  destruction  of  the 
abductor  fibers  of  the  recurrent  laryngeal  nerve  is  not  entirely 
known.  Theoretically  this  condition  is  due  either  to  a 
pressure  neuritis  resulting  from  the  edema  and  swelling  of 
the  tissues,  with  later  paresis  or  paralysis  as  the  result  of 
scar  tissue  formation  in  the  operated  area,  or  to  section, 
ligation,  or  trauma  during  the  operation.  On  account  of 
the  small  postoperative  mortality  rate  attending  thyroid- 
ectomies  exact  pathologic  data  are  not  easily  obtained. 

We  have  been  led  to  assume  that  the  superior  laryngeal 


DISEASES    OF    THYROID    AND    LARYNGEAL    FUNCTION        57 

nerve  is  entirely  a  sensory  nerve  and  that  the  motor  function 
of  the  larynx  is  dependent  entirely  upon  fibers  received 
from  the  recurrent  laryngeals.  Whether  this  is  a  fact  or 
not  remains  to  be  seen.  It  may  be  that  in  going  over  the 
experimental  work  upon  which  those  conclusions  are  based 
we  may  find  that  the  superior  laryngeal  nerve  possesses  a 
greater  degree  of  motor  function  than  has  been  heretofore 
supposed.  It  is  a  fact  that  after  injury  to  the  recurrent 
nerves  the  vocal  cords  lie  at  first  in  a  semi-abducted  position 
with  the  power  of  further  abduction  gone.  But  by  repeated 
voluntary  effort  the  patient,  in  attempting  to  speak,  adducts 
the  cords  repeatedly,  and  apparently  the  cords  come  to 
assume  a  fixed  position  nearer  to  the  median  line  than  if 
this  adductor  power  was  not  in  force.  In  consequence, 
there  is  an  ever-increasing  dyspnea.  These  cords  may 
finally  assume  a  position  so  nearly  approximate  that  on 
full  inspiration  the  aperture  does  not  appear  to  be  wide 
enough  to  admit  the  edge  of  a  ten-cent  piece.  At  this  stage 
these  patients  have  but  a  narrow  margin  of  safety. 

In  certain  patients  observation  of  the  larynx  is  beset 
with  certain  difficulties.  For  example,  it  is  difficult  to  secure 
satisfactory  observations  of  patients  with  the  curved  or 
infantile  type  of  epiglottis.  In  some  of  these  cases  it  is  im- 
possible to  see  the  cords  themselves  or,  at  best,  only  a  small 
portion  of  them.  Usually,  however,  the  movement  of  the 
arytenoid  bodies  can  be  sufficiently  seen  for  the  position 
and  movement  of  the  cords  to  be  judged. 

Occasionally  it  is  difficult  to  make  a  laryngeal  observa- 
tion on  a  patient  with  hypertrophied  tonsils,  for  in  the 
presence  of  very  large  tonsils  a  very  slight  contraction  of 
the  throat  is  sufficient  to  prevent  the  use  of  the  ordinary 
laryngeal  mirror. 

Patients   with    exophthalmic    goiter    in    particular    are 


58  THE    THYROID    GLAND 

exceedingly  nervous  and  their  throat  reflexes  are  very 
sensitive.  The  examination  of  a  patient  of  this  type  re- 
quires a  great  deal  of  patience  and  persistence  on  the  part 
of  the  laryngologist.  Repeated  seances  with  the  patient 
may  be  required  before  a  single  correct  observation  can  be 
made.  Whether  or  not  the  throat  of  some  of  these  cases 
shall  be  cocainized  is  a  delicate  question.  We  have  found 
that  by  daily  observations  during  a  period  of  from  one  week 
to  ten  days,  a  very  good  view  of  the  larynx  will  finally  be 
secured  even  in  the  most  difficult  individual. 

At  the  Cleveland  Clinic  all  goiter  cases  are  examined  by 
the  laryngologist  before  operation,  and  immediately  after 
they  leave  the  hospital  with  re-examinations  at  intervals  of 
from  thirty  days  to  six  months  or  whenever  it  is  possible  to 
secure  an  observation. 

This  experience  has  demonstrated  the  following  facts 
which,  we  believe,  should  be  emphasized,  since  they  bear 
directly  upon  the  safety  of  the  patient: 

1.  Any  laryngeal  impairment  which  is  the  result  of  a 
pathologic  condition  of  the  thyroid  gland  is  almost  invari- 
ably unilateral.    When  a  bilateral  involvement  exists  pre- 
vious to  operation  it  is  usually  caused  either  by  some  lesion 
in  the  central  nervous  system,  such  as  syphilis,  or  by  a 
malignant  condition  of  the  thyroid  which  has  passed  beyond 
the  limits  of  the  gland  itself  and  has  damaged  the  recurrent 
laryngeal  nerves. 

2.  The  size  of  the  goiter  does  not  seem  to  bear  any 
direct  relation  to  the  functional  impairment  of  the  laryngeal 
nerve.     Furthermore,  the  impaired  cord  is  not  necessarily 
on  the  same  side  as  the  largest  mass,  as  one  would  naturally 
expect,  probably  because  twisting  of  the  thyroid  box  and 
trachea  by  the  unilateral  growth  produces  pressure  on  the 
opposite  side. 


DISEASES   OF   THYROID   AND   LARYNGEAL   FUNCTION       59 

3.  The    degree    of    laryngeal    involvement    from    non- 
operative  causes  varies  from  paresis  to  an  actual  paralysis. 

4.  The  onset  of  the  condition  is  so  gradual  that  except 
for  some  fatigue  following  excessive  use  of  the  voice  the 
patient  is  unaware  of  any  lack  of  laryngeal  function,  for, 
coincidently  with  the  impairment  of  one  cord,  there  develops 
a  compensation  by  the  opposite  cord  which  is  sufficient  for 
the  maintenance  of  the  patient's  voice  and  respiration. 

In  the  first  series  of  185  cases  examined  before  operation, 
the  unilateral  interference  with  the  laryngeal  function  was 
found  in  27,  or  14.6  per  cent.  This  percentage,  however,  is 
probably  higher  than  will  be  the  case  when  several  thousand 
observations  have  been  made.  The  occasional  observer 
will  find  that  his  figures  do  not  agree  at  all  with  those  secured 
by  the  observation  of  a  large  number  of  cases.  For  instance, 
in  a  series  of  100  goiter  cases,  taken  in  groups  of  twenty, 
in  the  order  of  their  observation  we  found  in  one  group  six 
cases  of  abductor  paralysis,  in  another  two,  in  a  third  group 
nine,  and  so  on.  It  follows  that  the  occurrence  of  laryngeal 
involvement  in  any  one  of  these  groups  of  twenty  would 
not  agree  with  the  percentage  of  occurrence  in  the  total 
number  of  cases.  Our  experience  to  the  present  time  leads 
us  to  believe  that  ultimately  the  occurrence  of  impaired 
laryngeal  function  in  goiter  cases  prior  to  operation  will  be 
found  to  be  in  the  neighborhood  of  10  per  cent. 

The  importance  of  this  preoperative  observation  is 
self-evident.  In  the  first  place,  the  patient  should  be  made 
aware  of  the  fact  that  this  damage,  if  present,  is  the  result 
of  the  pathologic  condition  of  the  thyroid.  Second,  if  the 
surgeon  has  been  warned  that  this  condition  is  present  he 
will  take  unusual  care  in  all  manipulations  of  the  side 
opposite  to  the  damaged  nerve,  thereby  preventing  one  of 
the  most  distressing  postoperative  sequelae — bilateral  abduc- 


60  THE    THYROID   GLAND 

tor  paralysis.  Moreover,  the  preoperative  laryngeal  observa- 
tion obviates  the  possibility  of  attributing  to  the  surgeon 
any  damage  other  than  that  which  is  the  direct  result  of 
the  surgical  procedure. 

As  to  the  permanency  of  the  laryngeal  impairment 
which  results  from  pressure  by  the  thyroid  in  the  process 
of  its  enlargement,  we  can  say  only  that  in  certain  of  these 
cases  the  function  of  the  vocal  cord  has  been  regained  after 
thyroidectomy.  We  believe  that  in  these  cases  the  thyroid 
pressure  has  existed  for  only  a  short  time.  It  has  been 
stated  by  some  writers  that  when  the  pressure  has  been 
present  for  as  long  as  nine  months,  the  resultant  damage 
cannot  be  repaired.  We  believe,  however,  that  this  is  a 
somewhat  arbitrary  statement  which  may  be  revised  as 
knowledge  of  this  condition  and  of  its  etiology  is  extended. 

Nearly  all  writers  make  some  reference  to  the  assump- 
tion that  laryngeal  paralysis  may  result  from  toxemia.  In 
our  own  experience  we  have  never  seen  a  case  in  which  it 
has  appeared  that  the  laryngeal  impairment  has  been  the 
result  of  toxemia  associated  with  disease  of  the  thyroid. 
If  these  paralyses  were  due  to  toxemia  why  should  they  be 
unilateral?  And  why  should  only  the  abductor  fibers  be 
involved?  It  seems  much  more  probable  that  when  laryn- 
geal paralysis  is  associated  with  a  diseased  thyroid  gland, 
whether  the  onset  of  the  paralysis  be  before  or  after  opera- 
tion, it  may  be  explained  as  the  result  of  mechanical  pressure 
or  of  trauma,  rather  than  toxemia. 

Thus  far  we  have  discussed  the  unilateral  laryngeal 
paralysis  which  appears  prior  to  operation  as  being  due  to 
the  diseased  condition  of  the  thyroid  itself.  When  any  form 
of  laryngeal  paralysis  follows  a  surgical  procedure  there  is  a 
complete  loss  of  voice  which  lasts  for  from  a  few  days  to 
two  or  three  months.  If  one  of  the  larygneal  nerves  has 


DISEASES   OF   THYROID   AND   LARYNGEAL   FUNCTION       61 

been  severed,  the  loss  of  voice  is  immediate  and  is  accom- 
panied by  more  or  less  dyspnea. 

Many  patients  are  able  to  speak  immediately  after 
operation,  but  later  suffer  a  temporary  loss  of  voice.  In 
these  cases  the  loss  of  voice  is  probably  the  result  of  the 
edema  or  swelling  of  the  tissues  in  the  operative  area.  In 
certain  cases  the  pressure  from  the  scar  tissue  may  be  suffi- 
cient to  damage  the  vocal  cord  permanently.  The  loss  of 
function  on  the  part  of  one  of  the  vocal  cords  is  gradually 
compensated  by  an  increased  function  on  the  part  of  the 
opposite  cord,  so  that  within  a  reasonable  length  of  time 
the  voice  improves  markedly,  though  the  higher  tones  may 
be  somewhat  limited,  and  the  voice  may  become  husky  as 
the  result  of  fatigue.  Many  of  these  patients  have  a  very 
good  voice  in  the  morning,  but  complain  of  slight  hoarse- 
ness and  distress  if  they  have  been  compelled  to  use  the 
voice  a  good  deal  during  the  day. 

Bilateral  abductor  paralysis  following  surgery  of  the 
thyroid  gland  and  due  to  any  of  the  causes  described  above 
presents  a  distressing  postoperative  condition.  Immediately 
after  operation  patients  in  whom  this  condition  is  present 
have  little  or  no  more  difficulty  than  the  patients  with 
unilateral  paralysis.  As  far  as  the  voice  alone  is  concerned 
it  may  be  a  little  longer  before  it  returns,  but  ultimately  it 
approaches  the  normal,  since  the  adductor  power  of  the 
cords  is  not  lost.  The  reason  that  these  cases  do  not  present 
more  distressing  symptoms  immediately  after  operation 
undoubtedly  is  due  to  the  enforced  rest.  These  patients 
may  leave  the  hospital  apparently  in  almost  as  good  a  con- 
dition as  patients  with  unilateral  paralysis,  but  there  follows 
a  gradual  onset  of  dyspnea,  especially  on  exertion,  which 
is  very  significant.  The  cords  in  these  cases  are  at  first 
fixed  in  a  semi-abducted  position;  and  the  aperture  between 


62  THE    THYROID    GLAND 

the  cords,  instead  of  being  widened  during  normal  inspira- 
tion, remains  unchanged  or  sometimes  is  even  narrowed  if 
the  tensor  muscles  of  the  cord  are  affected,  and  the  edge  of 
the  relaxed  cord  is  sucked  inward.  When  this  is  the  case 
the  patient  when  asleep  develops  a  stridor  which  is  very 
distressing  to  his  family.  It  is  very  embarrassing  for  a 
patient  hi  this  condition  to  be  away  from  home  because  he 
is  unable  to  avoid  this  unpleasant,  noisy  breathing  during 
sleep. 

Another  serious  handicap  to  these  patients  is  their 
inability  to  expel  viscid  secretions,  in  consequence  of  which 
a  moderate  cold  or  mild  bronchitis  becomes  a  serious  men- 
ace, and  should  pneumonia  develop,  the  patient  is  almost 
certainly  doomed. 

It  follows  that  the  margin  of  safety  in  these  patients  is 
diminished  and  at  any  moment  it  may  be  necessary  to  con- 
sign them  to  a  tracheotomy  life  until  some  other  measures 
are  effected  whereby  to  remedy  the  condition. 

Until  recently  no  direct  surgical  attempts  have  been  made 
to  relieve  this  condition.  Chevalier  Jackson,  of  Philadel- 
phia, has  performed  cordectomy  in  three  cases,  operating 
by  the  direct  laryngoscopic  route.  Jackson  states  that 
he  believes  that  these  patients  regain  a  fair  voice  by 
the  vicarious  use  of  the  false  vocal  cords.  Whether  or  not 
this  will  be  the  operation  of  choice  we  are  unable  to  say,  but 
at  present  we  believe  that  unless  cordectomy  by  this  method 
is  performed  by  a  laryngologist  of  extreme  skill  in  direct 
laryngoscopic  methods,  it  will  prove  disastrous  to  the  patient. 

In  the  first  place  there  is  danger  that  the  cord  may  not 
be  completely  resected,  with  the  result  that  granulation 
tissue  and  scar  formation  will  practically  reproduce  the 
condition  of  stenosis.  It  is  essential  that  the  surgeon  bear 
in  mind  the  fact  that  the  true  vocal  cord  is  not  a  plain 


DISEASES   OF   THYROID   AND    LARYXGEAL   FUNCTION       63 

horizontal  band,  but  rather  the  inner  edge  of  a  triangular 
body  of  tissue  with  its  broad  base  toward  the  cartilage. 
Furthermore,  if  voice  is  to  be  secured  by  the  use  of  the 
false  cords,  these  must  not  be  damaged. 

The  problem  is  to  get  a  sufficiently  wide  aperture  estab- 
lished so  that  respiration  may  go  on  with  comfort,  and  to  do 
this  in  such  a  way  as  to  permit  the  patient  to  develop  a 
speaking  voice.  It  must  be  borne  in  mind  that  to  accomplish 
this  end  work  must  be  done  in  a  tube  of  small  caliber  and 
that  any  procedure  which  tends  to  produce  stenosis  of  the 
trachea  is  very  undesirable.  Various  solutions  have  sug- 
gested themselves,  most  of  which  have  their  disadvantages. 
Thus  we  have  considered  the  following  procedures : 

First,  the  possibility  of  creating  two  raw  surfaces  and 
anchoring  the  cords  back  to  the  lateral  walls  of  the  trachea 
with  the  hope  of  thereby  widening  the  aperture  between  the 
cords  and  holding  them  in  place  by  the  development  of 
adhesions  between  these  two  raw  surfaces:  second,  the 
complete  excision  of  both  cords  back  to  the  perichondrium, 
permitting  this  area  to  granulate  over:  third,  a  submucous 
resection  of  both  cords  and  closure  of  the  area  formerly 
represented  by  the  base  of  the  triangular  shaped  body  of  the 
cord  by  plastic  closure  of  the  mucous  membrane. 

Of  these  three  methods  the  last  one  has  seemed  to  be  the 
most  logical,  even  though  it  presents  great  difficulties. 

The  following  case  has  recently  been  operated  upon  by 
this  method:  The  patient,  a  woman  sixty  years  of  age.  who 
had  been  operated  upon  in  another  state  for  adenoma  of  the 
thyroid,  had  developed  bilateral  abductor  paralysis  with 
gradually  increasing  symptoms  of  dyspnea  and  stridor. 
She  had  lost  strength  rapidly  as  the  result  of  her  disturbed 
sleep  and  her  constant  apprehension  that  she  might  choke  to 
death.  Her  nervous  state  made  her  a  very  undesirable  risk. 
Laryngeal  examination  showed  bilateral  abductor  paraly-  - 


64  THE   THYROID    GLAND 

with  a  very  small  opening  between  the  cords,  the  edges  of 
the  cords  being  sucked  in  during  inspiration.  An  immediate 
tracheotomy  was  done  and  the  patient  given  a  period  of 
complete  rest.  She  had  a  moderate  degree  of  bronchitis 
which  made  tracheotomy  life  very  difficult  for  her,  and 
therefore  it  was  decided  to  make  a  submucous  resection 
of  both  cords  at  a  favorable  moment. 

This  was  done  under  a  combination  of  nitrous  oxid- 
oxygen  and  ether  delivered  into  the  trachea  through  a  tube 
fitting  the  tracheotomy  wound  snugly  enough  to  make  it 
fluid-tight.  The  larynx  was  split  in  the  median  line,  an 
incision  made  through  the  mucous  membrane  below  the 
level  of  the  cords,  and  a  light  pack  inserted  down  to  the 
tracheotomy  tube  to  prevent  any  fluid  from  entering  the 
trachea.  Working  from  below  upward  the  wound  was 
enlarged  in  the  median  line  until  both  false  and  true  cords 
were  exposed.  Incisions  were  then  made  running  parallel 
with  the  edge  of  the  true  cord  and  the  mucous  membrane 
was  dissected  free  in  both  the  downward  and  the  upward 
direction.  The  body  of  the  cord  was  excised  back  to  the 
lateral  wall  of  the  thyroid  box  and  the  free  edges  of  the 
mucous  membrane  stitched  together  on  either  side  with  very 
fine  linen.  The  larynx  was  then  closed  except  for  a  small 
wick  drain  in  the  lower  end  of  the  wound  just  above  the 
tracheotomy  tube. 

As  far  as  respiration  goes,  we  should  be  able  to  judge  the 
result  within  ninety  days.  As  for  voice  production  our  judg- 
ment should  be  deferred  for  many  months.  We  hope  that  a 
decided  forward  step  has  been  made  in  the  solution  of  this 
very  difficult  problem. 

Undoubtedly,  we  shall  begin  to  find  in  the  literature 
reports  of  cases  managed  along  this  or  similar  lines,  and 
the  prognoses  of  cases  of  bilateral-laryngeal  paralysis  will 
become  materially  improved. 


DIFFERENTIAL  DIAGNOSIS  OF  DISEASES  OF  THE 
THYROID  GLAND 

JOHN  PHILLIPS 


THE  thyroid  gland,  consisting  of  two  lateral  lobes  and 
an  isthmus,  surrounds  the  trachea  like  a  horseshoe.  The 
isthmus  covers  the  second  and  third  ring  of  the  trachea  and 
occasionally  extends  upward  in  front  of  the  thyroid  carti- 
lage or  even  the  cricoid.  Special  bands  of  connective  tissue 
known  as  the  cricothyroid  or  suspensory  ligament  pass 
upward  from  the  isthmus  and  lateral  lobes  of  the  thyroid 
to  form  an  attachment  with  the  cricoid  cartilage.  This 
attachment  is  important  because  it  is  responsible  for  the 
movement  upward  and  downward  of  the  gland  during 
deglutition.  Sometimes  the  thyroid  has  also  a  pyramidal 
lobe  which  extends  upward  in  the  median  line  from  the 
isthmus  to  the  hyoid  bone.  This  represents  the  remnant 
of  the  thyroglossal  duct  and  may  be  the  site  of  a  struma  or 
a  cyst.  Accessory  thyroid  glands  are  sometimes  present, 
being  situated  in  the  neck  in  the  neighborhood  of  the  hyoid 
bone  and  below  the  thyroid,  or  in  the  mediastinum  as  low 
down  as  the  arch  of  the  aorta. 

The  posterior  and  inner  surfaces  of  the  lateral  lobes  of 
the  thyroid  lie  in  contact  with  the  cricoid  and  thyroid 
cartilages,  the  trachea,  esophagus,  inferior  laryngeal  nerve, 
and  the  inferior  constrictor  of  the  pharynx.  It  is  important 
to  remember  these  relationships  because  when  the  gland  is 
enlarged,  pressure  on  these  structures  gives  rise  to  definite 
symptoms.  In  front  of  the  lateral  lobes  lie  the  superficial 
muscles  of  the  neck — the  sternohyoid,  sternothyroid,  omo- 

5  65 


66  THE    THYROID    GLAND 

hyoid,  and  a  small  portion  of  the  sternomastoid  muscle. 
To  the  outer  side  of  and  posterior  to  each  lateral  lobe  and 
covered  by  the  sternomastoid  muscle  lies  the  carotid  sheath, 
containing  the  common  carotid  artery,  the  external  jugular 
vein,  and  the  vagus  nerve.  When  this  lobe  is  enlarged  the 
carotid  artery  is  displaced  outward  and  backward.  This 
outward  displacement  serves  to  differentiate  thyroid  enlarge- 
ments from  glandular  swellings  or  tumors  in  this  region, 
as  the  artery  passes  centrally  through  the  inflammatory 
mass. 

One  of  the  two  superior  thyroid  arteries  enters  the 
superior  pole  of  each  lateral  lobe,  one  of  the  inferior  thyroid 
arteries  enters  each  inferior  pole.  In  many  cases  of  goiter 
these  arteries  are  considerably  increased  in  size,  so  that  a 
distinct  pulsation  can  be  felt  throughout  the  entire  gland. 
The  small  ima  arteries  which  arise  usually  from  the  aorta 
enter  the  lower  portion  of  the  isthmus,  from  which  the  cor- 
responding veins  pass  to  the  innominate  veins.  The  latter 
are  of  importance  because  they  are  sometimes  the  seat  of 
air  embolism.  One  of  the  recurrent  laryngeal  nerves  passes 
to  the  inner  side  of  each  lateral  lobe,  a  position  which  renders 
it  liable  to  compression  by  a  struma  or  to  injury  during  the 
surgical  removal  of  a  goiter,  with  resultant  paralysis  of  the 
abductor  muscle  of  the  corresponding  vocal  cord. 

Various  complicated  pathologic  classifications  of  dis- 
eases of  the  thyroid  gland  have  been  worked  out  by  different 
observers,  from  among  which  I  think  the  following  headings 
are  most  convenient  for  the  practical  consideration  of  the 
clinician : 

1.  Simple    goiter   which    includes    the   hyperplasias   of 
the  gland  seen  at  puberty. 

2.  Colloid  goiter. 

3.  Adenoma  of  the  thyroid. 


DIFFERENTIAL   DIAGNOSIS   OF   DISEASES   OF   THYROID      67 

4.  Exophthalmic  goiter,  hyperthyroidism. 

5.  Myxedema,  hypothyroidism. 

6.  Tumors  of  the  thyroid  gland. 

7.  Inflammations  of  the  thyroid. 

SIMPLE  GOITER 

Under  the  term  "simple  goiter"  are  included  the  hyper- 
plasias  of  the  gland  which  are  very  frequently  seen  at 
puberty  or  in  adolescence  (Fig.  8).  These  occur  more  com- 


Fig.  8. — Adolescent  goiter. 

monly  in  certain  districts  among  which  the  region  of  the 
Great  Lakes  is  one  of  the  most  important  in  this  country. 
As  a  rule,  in  simple  hyperplasia  there  is  a  diffuse  enlarge- 
ment of  the  entire  gland  affecting  equally  all  its  parts, 


68 


THE    THYROID    GLAND 


although  in  some  instances  one  lateral  lobe  will  be  more 
enlarged  than  the  other.  In  cases  of  simple  goiter  the 
size  of  the  gland  increases  during  menstruation  and  also 
during  pregnancy.  As  a  rule  there  are  no  symptoms  present 
in  these  cases  and  treatment  is  usually  sought  because  of 
the  disfigurement  of  the  neck  (Fig.  9).  The  diagnosis  of 


Fig.  9. — Enormous  diffuse  simple  goiter. 

simple  goiter  is  easy  and  its  differentiation  from  other  con- 
ditions presents  no  difficulty. 

COLLOID  GOITER 

The   only   symptoms   presented   by   colloid   goiter   are 
those  due  to  the  resultant  compression  of  the  surrounding 


Fig.  10. — Colloid  goiter. 

structures.     Like  the  simple  goiter,  a  colloid  goiter  may 
present  a  uniform  enlargement  of  the  entire  gland  or  one 


DIFFERENTIAL   DIAGNOSIS    OF    DISEASES    OF    THYROID      69 

lobe  may  be  much  more  enlarged  than  the  other  (Figs.  10, 
11).     The  muscles  covering  the  growth  may  become  greatly 


Fig.  11. — Colloid  goitc-r. 

stretched  and  atrophied,  and  if  the  goiter  is  of  great  size  the 
superficial  muscles  may  not  be  sufficient  to  support  it  so 


Fig.  12. — Pendulous  goiter. 


70  THE   THYROID   GLAND 

that  it  may  descend  from  its  own  weight  and  become  almost 
pendulous  (Fig.  12).  The  larynx  and  trachea  may  be  greatly 
compressed,  the  character  of  the  resultant  deformity  of  these 
structures  depending  upon  the  relative  enlargement  of  the 
different  portions  of  the  gland.  Thus,  if  the  isthmus  is  en- 
larged, there-will  result  an  anteroposterior  compression.  If 
one  lateral  lobe  is  particularly  enlarged,  the  trachea  may  be 
compressed  and  displaced  to  one  side;  or  if  both  lateral 
lobes  are  greatly  enlarged,  the  trachea  may  be  flattened 
from  side  to  side.  If  the  enlargement  in  the  two  lobes  is 
at  different  levels,  the  trachea  may  assume  an  S  shape. 
As  a  result  of  this  tracheal  compression  the  patient  may 
have  great  difficulty  in  breathing,  with  a  resultant  inspira- 
tory  stridor.  The  patient  may  have  a  persistent,  irritating 
cough,  which  differs  from  the  cough  which  results  from  com- 
pression of  the  recurrent  laryngeal  nerve,  the  latter  occurring 
in  paroxysms  and  being  of  a  curious  resounding  character 
without  any  definite  expectoration.  If  the  esophagus  is 
compressed  there  will  be  difficulty  in  deglutition,  especially 
when  the  patient  attempts  to  swallow  solids.  The  blood- 
vessels may  be  very  much  displaced,  particularly  the 
common  carotid,  which  is  displaced  outward.  As  the 
goiter  enlarges  it  may  descend  into  the  superior  mediasti- 
num and  give  rise  to  trouble  there  as  the  result  of  compres- 
sion of  the  mediastinal  contents. 

INTRATHORACIC  GOITER 

Sometimes  an  enlargement  of  the  lower  portion  of 
either  lateral  lobe  or  the  isthmus  may  descend  within  the 
thoracic  cavity  and  form  the  complication  called  intra- 
thoracic  goiter  (Fig.  13).  Sometimes  such  a  goiter  develops 
from  an  accessory  gland  in  the  superior  mediastinum  (Fig. 
14).  The  superior  mediastinum  is  bounded  in  front  by  the 


DIFFERENTIAL   DIAGNOSIS    OF    DISEASES    OF   THYROID      71 


Fig.  13. — Intrathoracic  goiter. 


Fig.  14.— Substernal  goiter  with  two  metastatic  abscesses  in  lungs. 

manubrium  sterni  and  the  upper  three  ribs,  posteriorly  by 
the  upper  three  dorsal  vertebrae,  in  front  of  which  lie  the 
trachea  and  the  esophagus,  and  below  by  the  arch  of  the 


72  THE    THYROID    GLAND 

aorta.  Goiters  which  arise  from  the  isthmus  and  lie  in  the 
median  portion  of  the  mediastinum  compress  the  trachea 
and  the  esophagus,  and  may  also  displace  the  aorta  down- 
ward. In  cases  of  enlargement  of  the  lateral  lobe  of  the 
thyroid  the  trachea  may  be  displaced  and  compressed  from 
side  to  side,  and  if  there  is  a  double  intrathoracic  goiter 
involving  both  lobes  the  trachea  may  be  twisted  on  itself,  as 
well  as  compressed,  thus  resembling  the  deformity  seen  in 
scoliosis  of  the  spine.  There  is  always  a  greal  deal  of  inter- 
ference with  the  venous  trunks,  in  some  instances  even  to 
the  extent  of  causing  almost  complete  occlusion  of  the  supe- 
rior vena  cava  as  illustrated  by  the  following  case: 

The  patient,  a  male,  sixty-two  years  of  age,  was  seen 
first  on  March  7,  1921.  He  had  always  been  well  until  ten 
years  before,  when  his  face  began  to  swell,  his  lips  and  face 
became  cyanosed,  and  the  veins  over  his  body,  particularly 
over  the  chest  and  neck,  were  very  much  distended.  He 
had  never  been  very  short  of  breath  and  never  had  any 
choking  spells.  He  had  noticed  for  at  least  ten  years  or 
more  that  he  had  a  goiter,  but  had  never  been  troubled 
with  palpitation  of  the  heart,  and  had  only  occasionally 
noticed  a  shaking  of  the  hands. 

Examination  showed  a  well-marked  cyanosis  of  the  face 
and  hands,  particularly  of  the  lips.  The  eyes  showed  a 
moderate  exophthalmos,  with  some  slight  lagging  of  the 
upper  lid  on  looking  downward  and  increased  widening  of 
the  palpebral  fissure.  There  was  no  ocular  palsy.  There 
was  an  enlargement  of  the  thyroid  gland,  particularly  of 
the  right  lobe,  which  contained  a  hard,  firm  adenomatous 
nodule  about  the  size  of  a  hen's  egg.  There  was  also  a 
similar  nodule  in  the  isthmus  about  the  size  of  a  hickory 
nut.  The  jugular  veins  were  very  much  distended,  and 
there  was  extreme  distention  of  the  veins  over  the  chest 


DIFFERENTIAL   DIAGNOSIS    OF    DISEASES    OF    THYROID      73 

and  anterolateral  portions  of  the  abdomen  as  shown  by  the 
accompanying  picture  (Fig.  15). 

The  examination  of  the  chest  showed  diminished  expan- 
sion of  the  base  of  the  right  lung.  There  was  increased 
tactile  fremitus  at  the  apex  of  the  right  lung  in  front  and 


Fig.  15. — Venous  thrombosis  from  obstruction  due  to  intrathoracic  goiter. 

behind,  while  at  the  base  of  the  right  lung,  from  the  angle 
of  the  scapula  downward,  the  tactile  fremitus  was  absent. 
The  tactile  fremitus  over  the  left  lung  was  normal.  There 
was  more  or  less  impairment  of  resonance  all  over  the  right 
side  of  the  chest  with  dulness  over  the  base  of  the  right 
lung  from  the  level  of  the  angle  of  the  scapula  downward. 


74  THE    THYROID    GLAND 

There  was  also  extensive  impairment  of  resonance  in  the 
first,  second,  and  third  interspaces  below  the  clavicle. 
Over  this  latter  area  the  breath  sounds  were  bronchial  in 
character,  and  a  few  coarse  rales  could  be  heard.  Over  the 
base  of  the  right  lung  posteriorly  there  was  almost  complete 
absence  of  breath  sounds. 

The  heart  was  enlarged  in  both  diameters,  with  a 
systolic  murmur  at  the  apex.  The  pulse  was  somewhat 
irregular,  arhythmic,  rate  100;  blood-pressure,  systolic  126, 
diastolic  76.  The  liver  edge  could  be  easily  felt  and  there 
was  edema  of  the  lower  extremities.  The  Wassermann 
reaction  was  negative.  The  urine  showed  a  trace  of  albumin 
and  some  granular  casts.  The  blood  count  showed  red  blood 
cells  4,290,000,  white  blood  cells  6400,  and  hemoglobin  80 
per  cent.  The  differential  count  showed  polymorphonuclear 
neutrophils  60  per  cent.,  small  lymphocytes  32  per  cent., 
large  lymphocytes  2.5  per  cent.,  and  transitionals  5.5  per 
cent.  The  blood  chemistry  showed  blood  urea  29  mgm.  per 
100  c.c.,  blood-sugar  112  mgm.  per  100  c.c.,  and  blood 
chlorids  580  mgm.  per  100  c.c. 

Fluoroscopic  examination  of  the  chest  revealed  a  homo- 
geneous shadow  occupying  the  entire  upper  lobe  of  the  right 
lung.  The  aortic  arch  was  prominent.  The  trachea  was 
not  displaced.  The  mass  was  definitely  connected  with 
the  mediastinum  and  pulsated,  but  not  with  the  expansile 
pulsations  characteristic  of  aneurysm.  On  deep  respiration 
and  deglutition  the  shadow  did  not  separate  from  the  aortic 
shadow. 

The  oblique  view  was  of  no  aid  in  determining  the  char- 
acter of  the  mass.  The  entire  lower  lobe  of  the  lung  was 
consolidated,  having  an  irregular  upper  border  with  a 
dense  base,  the  picture  indicating  fluid  in  the  base  with  an 
inflammatory  process  above.  The  middle  lobe  of  the  lung 


DIFFERENTIAL   DIAGNOSIS    OF   DISEASES    OF   THYROID      75 

was  free  from  involvement.  The  heart  was  apparently 
normal  in  shape  and  position,  but  somewhat  increased  in 
size.  From  the  fluoroscopic  findings  the  diagnosis  was 
probable  aneurysm.  Plates  of  the  chest  were  made  which 
confirmed  the  fluoroscopic  findings,  with  the  exception 
that  a  rather  indistinct  regular  shadow  could  be  seen  within 
the  homogeneous  mass.  This  was  interpreted  as  a  probable 
saccular  aneurysm  with  luetic  involvement  of  the  rest  of 
the  lung. 

In  addition  to  this,  the  diagnosis  included  adenoma  of 
the  thyroid,  chronic  myocarditis  with  beginning  decom- 
pensation, and  hydrothorax  with  infiltration  at  the  base 
of  the  right  lung. 

The  patient  was  advised  to  rest,  and  fifteen  minims  of 
tincture  of  digitalis  with  five  grains  of  sodium  iodid  three 
times  a  day  were  prescribed.  We  expected  him  to  return  in 
two  weeks  for  further  observation,  but  he  did  not  return 
until  September  12,  1921.  He  had  been  taking  the  iodid 
regularly,  and  had  lost  forty  pounds  in  weight;  the  edema 
of  the  extremities  had  disappeared  and  his  cyanosis  was 
somewhat  decreased.  His  pulse-rate,  however,  had  increased 
to  120.  He  showed  a  marked  tremor  of  the  hands,  his  skin 
was  very  moist,  and  he  had  been  troubled  with  diarrhea. 

Examination  of  the  chest  showed  that  there  was  some 
diminution  in  the  area  of  dulness  below  the  clavicle  on  the 
right  side.  The  signs  of  fluid  at  the  base  of  the  right  lung 
had  disappeared.  x-Ray  examination  of  the  chest  at  this 
time,  plates  giving  anterior,  posterior,  and  oblique  views 
being  taken,  showed  quite  a  contrast  to  the  picture  taken 
at  the  first  examination.  All  the  inflammatory  involvement 
of  the  upper  lobe  had  disappeared,  except  for  a  dense, 
thickened  pleura  between  the  upper  and  the  middle  lobes 
extending  to  the  periphery  of  the  lung.  The  shadow  which 


76 


THE    THYROID    GLAND 


was  seen  within  the  mass  at  the  first  examination,  in  these 
plates,  appears  distinct  and  clear,  and  in  the  oblique  view 


Fig.  16. — Radiograph  of  patient  shown  in  Fig.  15,  showing  well-defined  out- 
line of  intrathoracic  goiter. 

is  seen  to  be  continuous  with  a  goiter  shadow  in  the  neck, 
and  separated  from  the  aorta  (Figs.  16,  17). 

There  is  very  little  doubt  that  the  development  of  the 


DIFFERENTIAL   DIAGNOSIS   OF   DISEASES    OF   THYROID      77 

symptoms  of  hyperthyroidism  was  due  to  the  long-continued 
administration  of  sodium  iodid,  because  in  the  preceding 
month,  since  the  iodid  had  been  discontinued,  the  patient 


Fig.  17. — Radiograph  of  patient  shown  in  Fig.  15,  oblique  view. 

had  begun  to  gain  in  weight,  the  tremor  of  the  hands  was 
less,  and  he  was  not  so  conscious  of  the  palpitation  of  the 
heart. 


78  THE    THYROID    GLANDS 

Upon  the  sudden  death  of  this  patient,  shortly  after  his 
last  visit,  there  was  found  at  autopsy  a  marked  hyperplasia 
of  both  lobes  of  the  thyroid  gland  and  of  the  isthmus,  with 
an  intrathoracic  goiter  about  the  size  of  a  small  orange, 
extending  from  the  lower  pole  of  the  right  lateral  lobe.  This 
was  covered  by  a  thick  capsule,  which  was  adherent  to  the 
posterior  and  inner  portion  of  the  right  apex  of  the  lung,  to 
the  right  vagus  nerve,  and  to  the  right  subclavian  and  in- 
nominate veins.  The  right  innominate  vein  was  almost 
completely  obliterated  by  fibrosis,  doubtless  resulting  from 
the  organization  of  a  thrombus. 

These  autopsy  findings  justified  our  previous  conclusion 
that  the  enlargement  of  the  veins  of  the  trunk  and  neck  were 
the  result  of  obstruction  of  the  venous  return  to  the  heart 
through  the  superior  vena  cava  (Fig.  18). 

The  outstanding  subjective  symptoms  of  intrathoracic 
goiter  are,  therefore,  as  one  would  expect,  the  mechanical 
result  of  the  position  and  degree  of  enlargement  in  the 
individual  case. 

Dyspnea,  which  is  usually  continuous  and  associated  with 
an  inspiratory  stridor,  is  present  in  most  cases.  In  some 
instances  there  may  be  choking  spells  which  are  very  serious. 
These  are  more  likely  to  occur  when  the  intrathoracic  goiter 
is  not  very  large  and  is  situated  in  the  median  line,  so  that 
it  may  slip  in  and  out  of  the  superior  strait  of  the  medias- 
tinum. 

Coughing  is  another  troublesome  symptom.  This  is 
due  either  to  the  irritation  of  the  trachea  resulting  from 
compression,  or  in  some  instances  to  irritation  of  the  recur- 
rent laryngeal  nerve.  Hoarseness  from  the  same  causes  is 
also  present.  Sometimes  these  patients  complain  of  wheez- 
ing, which  also  is  due  to  compression  of  the  windpipe. 
Dysphagia,  especially  difficulty  in  swallowing  solid  food, 
is  a  not  infrequent  symptom. 


DIFFERENTIAL   DIAGNOSIS    OF   DISEASES    OF    THYROID      79 


80  THE    THYROID    GLAND 

Cardiac  disturbance  is  sometimes  present  in  cases  of 
intrathoracic  goiter  as  the  result  of  compression  and  re- 
sultant irritation  of  the  sympathetic  and  vagus  nerves. 
This  may  manifest  itself  in  tachycardia,  bradycardia,  and 
various  cardiac  arhythmias.  Sometimes  there  may  be 
attacks  of  paroxysmal  tachycardia. 

On  physical  examination,  one  of  the  most  striking 
feature's  of  intrathoracic  goiter  is  the  distention  of  the 
veins  in  the  upper  part  of  the  thorax.  These  veins  may  be 
quite  large,  and  extend  outward  over  the  shoulders  as 
shown  in  the  case  described  above.  Their  enlargement  is 
more  marked  on  one  side  than  on  the  other,  depending  upon 
whether  the  goiter  arises  from  the  right  or  left  lateral  lobe. 
On  palpation,  when  the  patient  swallows,  sometimes  the 
upper  part  of  the  intrathoracic  goiter  can  be  felt  to  ascend 
into  the  superior  strait.  Displacement  of  the  trachea  to 
the  right  or  left  may  also  be  noted.  Percussion  often  dis- 
closes a  retrosternal  dulness  or  dulness  on  either  side  of  the 
sternal  border. 

Fluoroscopic  examination  is  of  great  assistance  in  the 
diagnosis  of  intrathoracic  goiter.  The  tumor  shows  a  con- 
vexity laterally,  and  if  the  goiter  is  nodular  the  surface 
may  be  uneven.  The  tumor  may  pulsate  because  of  its 
close  proximity  to  the  aorta.  For  this  reason  it  may  often 
be  difficult  to  differentiate  between  an  intrathoracic  goiter 
and  aneurysm.  Under  the  fluoroscope,  however,  it  will  be 
seen  that  except  in  malignant  cases  the  intrathoracic  goiter 
changes  its  position  during  inspiration  and  expiration, 
and  also  during  the  act  of  swallowing,  so  that  an  angle  is 
formed  between  the  tumor  and  the  ascending  aorta,  whereas 
the  shadow  of  an  aneurysm  remains  continuous  with  the 
aorta. 


DIFFERENTIAL   DIAGNOSIS   OF   DISEASES   OF   THYROID      81 
ADENOMA  OF  THE  THYROID 

Adenomata  of  the  thyroid  are  manifested  by  an  enlarge- 
ment of  the  gland  that  is  nodular  in  character  (Figs.   19, 


Fig.  19. — Multiple  adenomata  of  the  thyroid. 


Fig.  20. — Adenoma  of  the  thyroid. 

20).  They  may  be  single  or  multiple,  and  vary  greatly  in 
size.  They  can  be  readily  differentiated  on  palpation  by  the 
fact  that  usually  they  are  harder  in  consistency  than  the 
other  portions  of  the  gland.  In  some  instances,  however, 


82  THE   THYROID   GLAND 

they  become  cystic,  and  then  are  quite  soft  in  consistency. 
Occasionally  calcification  occurs.  Adenomata  of  the  thyroid 
are  much  more  likely  to  cause  asymmetric  enlargements  of 
the  thyroid  than  any  other  condition.  Sometimes  hemor- 
rhage may  occur  in  them  as  the  result  of  severe  exertion. 
One  such  case  I  saw  five  years  ago  in  a  boy  sixteen  years  of 
age,  who,  while  wrestling  with  some  other  boys  at  the 
place  where  he  was  employed,  developed  a  sudden  acute 
swelling  of  the  neck  which  caused  considerable  difficulty 
in  breathing  because  of  its  compression  of  the  trachea. 
This,  however,  subsided  in  the  course  of  ten  days,  and  most 
of  the  swelling  entirely  disappeared. 

In  the  majority  of  cases  the  general  symptoms  of 
adenomata  of  the  thyroid  differ  in  no  way  from  the  symp- 
toms of  colloid  goiter.  In  other  words,  as  a  rule  the  only 
symptoms  are  those  resulting  from  the  compression  of  the 
surrounding  structures.  This  is  not  always  true,  however, 
because  sometimes  hyperthyroidism  may  develop  in  patients 
with  adenomata.  One  interesting  feature  of  the  cases  of 
adenomata  with  hyperthyroidism  is  that  the  toxic  symp- 
toms, as  a  rule,  do  not  develop  until  after  the  adenomata 
have  been  present  for  a  number  of  years,  and  they  are 
more  likely  to  be  accompanied  by  cardiac  disturbances  in 
the  form  of  arhythmia  and  myocardial  changes  than  the 
ordinary  case  of  hyperthyroidism.  This  characteristic 
probably  is  the  result  of  the  long-continued  toxemia. 

EXOPHTHALMIC  GOITER  OR  HYPERTHYROIDISM 

Other  names  applied  to  this  condition  are  toxic  goiter, 
thyrotoxicosis,  Basedow's  disease,  Parry's  disease,  Graves' 
disease.  Sir  William  Osier  has  stated  that  if  the  name  of 
any  one  physician  is  applied  to  the  disease,  the  credit  should 
go  to  Parry. 


DIFFERENTIAL    DIAGNOSIS    OF   DISEASES    OF    THYROID      83 

The  cardinal  symptoms  of  exophthalmic  goiter  are: 
(1)  the  presence  of  an  enlarged  thyroid  or  struma;  (2) 
exophthalmos;  (3)  tremor;  (4)  tachycardia  (Fig.  21). 

Changes  in  the  Thyroid  Gland. — The  thyroid  may  show 
a  symmetric  enlargement,  although  in  some  cases  there 
may  not  be  very  much  increase  in  the  size  of  the  gland. 
However,  physical  examination  of  the  thyroid  does  not 


Fig.  21. — Typical  case  of  exophthalmic  goiter. 


always  give  us  a  true  estimate  of  the  size  of  the  gland,  as  at 
operation,  some  of  the  cases  in  which  the  gland  appeared 
quite  small,  show  quite  marked  enlargement.  Some- 
times the  gland  is  firm  and  presents  a  granular  feeling  to 
the  palpating  hand  on  account  of  the  irregularity  due  to 
the  hyperplasia;  at  other  times  it  feels  soft,  almost  cystic. 
The  superior  thyroid  artery  can  often  be  felt  to  pulsate 


84  THE    THYROID    GLAND 

much  more  vigorously  than  in  the  normal  gland.  In  fact, 
the  whole  gland  may  show  an  expansile  pulsation  almost 
like  that  of  an  aneurysm.  Frequently,  as  a  result  of  the 
increased  vascularity,  a  systolic  murmur  can  be  heard. 
Occasionally  also  a  thrill  can  be  felt  on  palpation. 

Eye  Signs. — The  eye  signs  present  some  of  the  most 
characteristic  features  of  this  disease.  There  is  a  noticeable 
staring  expression  and  exophthalmos,  usually  bilateral,  but 
occasionally  unilateral,  is  present  in  a  large  proportion  of 
the  cases.  The  degree  of  exophthalmos  varies  a  great  deal, 
sometimes  being  so  extreme  that  the  eyeball  is  displaced 
from  the  socket.  Riesman  has  described  one  rare  instance 
in  which  a  murmur  was  plainly  audible  over  the  ball  of  the 
eye.  There  is  a  lagging  of  the  upper  lid  on  looking  down- 
ward (von  Graefe's  sign).  The  slit  between  the  two  eyelids 
is  widened  so  that  even  the  sclera  will  show  between  the 
lid  and  the  iris  (Dalrymple's  sign).  There  is  infrequent 
winking  (Stellwag's  sign),  and  the  power  of  convergence  is 
often  decreased  (Moebius'  sign).  There  may  be  epiphora 
or  the  tears  may  be  diminished.  In  occasional  cases  paresis 
of  some  of  the  external  ocular  muscles  has  been  described. 
Sometimes,  too,  there  is  quite  a  marked  pigmentation  of 
the  eyelids. 

Vascular  Symptoms. — Tachycardia  is  such  a  common 
symptom  that  the  presence  of  Graves'  disease  should  be  sus- 
pected in  any  case  in  which  there  is  a  persistently  rapid  pulse. 
The  rate  may  vary  from  90  to  100  in  the  milder  cases 
to  from  160  to  180  in  the  more  severe  cases.  The  volume 
of  the  pulse  is  large,  and  there  is  a  marked  throbbing  of 
all  the  accessible  arteries.  The  patient  also  complains  of  a 
subjective  sensation  of  throbbing.  This  is  particularly 
marked  when  he  puts  his  head  on  the  pillow  at  night. 
Various  forms  of  cardiac  arhythmias  are  present,  and  in  the 


DIFFERENTIAL   DIAGNOSIS   OF   DISEASES   OF   THYROID      85 

late  stages  of  exophthalmic  goiter  there  may  be  well-defined 
signs  of  myocardial  degeneration  and  cardiac  decompensa- 
tion. The  heart  may  show  some  enlargement,  and  a  systolic 
murmur  may  be  heard  over  the  precordium.  The  blood- 
pressure  may  show  very  little  change  except  that  the  systolic 
pressure  may  be  slightly  increased,  and  the  diastolic  may 
be  lower  than  normal.  In  other  words,  the  pulse-pressure 
is  increased.  The  cardiac  manifestations  have  been  des- 
cribed at  length  in  another  section  of  this  volume. 

Blood  Changes. — The  most  characteristic  change  in  the 
blood-picture  in  hyperthyroidism  is  the  presence  of  a 
moderate  degree  of  lymphocytosis. 

Vasomotor  and  Trophic  Symptoms. — One  common  sub- 
jective symptom  is  the  sensation  of  warmth  and  there  is  a 
tendency  to  flushing  of  the  skin.  The  skin,  as  a  rule,  is 
very  moist  and  has  a  soft  feeling.  There  is  very  free  per- 
spiration of  the  extremities  and  from  the  armpits.  Dermat- 
ographia  is  nearly  always  present  and  the  pilomotor  reflex 
is  increased.  Very  often  there  is  pigmentation  of  the  skin. 
This  may  occur  on  various  parts  of  the  body,  but  is  most 
marked  on  the  face.  Occasionally  well-defined  areas  of 
vitiligo  or  leukoderma  are  seen  on  the  neck  or  other  parts 
of  the  body  or  extremities  (Fig.  22).  The  hair  is  scanty  on 
the  body  and  the  hair  on  the  scalp  has  a  tendency  to  fall 
out.  Very  often  the  nails  show  signs  of  degeneration. 
Pruritus  may  be  a  persistent  and  unpleasant  symptom. 

Respiratory  Symptoms. — The  respirations  are  increased 
in  rate  and  are  superficial  and  irregular.  The  excursion  of 
the  chest  shows  a  diminished  amplitude.  The  patient  com- 
plains of  shortness  of  breath  and  at  frequent  intervals  will 
take  a  very  deep  inspiration  to  overcome  the  feeling  of  air 
hunger.  The  voice  is  often  hoarse  and  the  patient  is  often 
troubled  with  a  cough.  These  last  two  symptoms  may  be 


86 


THE    THYROID    GLAND 


due  either  to  a  compression  of  the  trachea  or  to  interference 
with  the  recurrent  laryngeal  nerve. 

Digestive  Disturbances. — In  the  early  stages  the  appe- 
tite, as  a  rule,  is  increased.    In  fact,  the  excessive  appetite 


Fig.  22. — Lack  of  pigmentation  of  skin  sometimes  associated  with  hyper- 

thyroidism. 

presents  a  strong  contrast  to  the  great  loss  in  weight.  In 
the  later  stages,  however,  there  may  be  persistent  nausea, 
vomiting,  and  belching  of  gas.  Very  frequently,  too, 
diarrhea  is  a  troublesome  symptom. 


DIFFERENTIAL    DIAGNOSIS    OF   DISEASES    OF    THYROID      87 

Urinary  and  Genital  Symptoms. — Frequency  of  urina- 
tion and  the  passage  of  large  quantities  of  urine  are  not 
uncommon  symptoms.  There  is  a  diminished  tolerance  to 
carbohydrates,  so  that  often  sugar  will  appear  in  the  urine. 
Sometimes  there  is  a  sexual  hyperexcitability,  but  usually 
there  is  a  diminution  both  of  libido  and  of  potentia. 

Metabolic  Disturbances. — In  a  severe  case  the  patient 
loses  weight  very  fast.  This  is  due  to  the  rapid  oxidation 
of  the  tissues  and  the  burning  up  of  his  own  tissue  protein. 
Therefore  the  basal  metabolism  as  shown  by  the  calorimeter 
is  greatly  increased.  Estimation  of  the  basal  metabolism 
is,  therefore,  a  valuable  diagnostic  measure  in  cases  of 
hyper  thy  roidism.  There  is  also  an  increased  sensitiveness 
in  these  patients  to  the  injection  of  adrenalin.  This  sensi- 
tiveness is  manifested  by  increase  in  the  rate  of  the  heart- 
beat, by  increased  blood-pressure,  and  by  hyperexcitability 
after  an  injection  of  five  to  seven  minims  of  adrenalin 
(Goetsch  test).  Cases  of  toxic  goiter  often  have  a  slight 
elevation  of  temperature. 

Nervous  and  Mental  Disturbances. — Patients  with  ex- 
ophthalmic goiter  are  extremely  nervous  and  apprehensive- 
In  many  instances  they  seem  to  be  in  the  state  of  constant 
fear.  Very  often  they  are  irritable  and  given  to  fits  of  temper. 
They  are  very  restless  and,  as  a  rule,  the  mental  processes 
are  not  as  keen  as  when  they  are  in  normal  health.  Some- 
times they  are  quite  forgetful.  In  severe  cases  the  mental 
symptoms  may  take  the  form  of  an  active  delirium.  In 
others  there  may  be  great  depression  amounting  to  melan- 
cholia. A  fine  tremor  of  the  hands  varying  in  rate  from 
seven  to  ten  per  second  is  a  striking  feature. 

Muscular  Symptoms. — These  patients  complain  of  great 
weakness  and  extreme  exhaustion  after  any  severe  or  pro- 
longed effort.  Sometimes  they  complain  of  a  sudden  giving 


88  THE    THYROID    GLAND 

way  of  the  knees.    At  times,  too,  they  have  muscular  cramps 
of  the  extremities. 

DIFFERENTIAL  DIAGNOSIS  OF  HYPERTHYROIDISM 

Neurasthenia.— In  the  differential  diagnosis  of  cases  of 
hyperthyroidism  we  must  take  into  consideration  the  fact 
that  it  is  very  difficult  to  differentiate  some  forms  of  nervous 
exhaustion  or  simple  neurasthenia  from  the  mild  cases  of 
hyperthyroidism.  In  a  case  of  neurasthenia,  however,  the 
pulse  slows  down  to  normal  as  soon  as  the  patient  is  put  at 
rest  and  the  basal  metabolism  is  not  increased. 

Neurocirculatory  Asthenia. — Another  condition  which 
has  given  rise  to  a  great  deal  of  difficulty  in  differential 
diagnosis  is  neurocirculatory  asthenia  (irritable  heart), 
which  was  seen  so  frequently  among  soldiers  during  the 
last  war.  This  condition,  which  was  first  described  during 
the  Civil  War  by  Da  Costa,  simulates  hyperthyroidism 
very  closely.  It  occurs  after  infections  or  in  individuals 
who  have  shown  evidence  of  physical  inferiority  from  the 
time  of  birth.  These  individuals  are  delicate  as  babies 
and  very  often  present  evidence  of  rickets.  As  they  be- 
come older  they  are  unable  to  take  part  in  the  games 
with  other  children,  and  when  they  reach  the  age  of  tak- 
ing up  some  trade  they  always  choose  some  line  of  work 
which  requires  very  little  physical  exertion.  These  patients 
complain  of  dizziness  when  standing  in  an  upright  position; 
they  also  complain  of  palpitation  of  the  heart  and  throbbing 
of  the  vessels;  they  often  complain  of  pain  in  the  precordium 
and  of  tenderness  of  the  pectoral  muscles.  They  perspire 
very  freely,  and  very  often  faint  when  they  stand  for  a 
long  time.  Many  of  these  cases  have  digestive  disturbances 
and  a  large  proportion  of  them  have  visceroptosis.  The 
cardiac  rate,  as  stated  above,  is  very  much  increased.  They 


DIFFERENTIAL   DIAGNOSIS    OF    DISEASES    OF   THYROID       89 

have  tremor  of  the  fingers  and  cyanosis  of  the  hands,  very 
free  perspiration,  and  very  marked  dermatographia. 

In  fact,  in  many  instances  the  absence  of  ocular  symp- 
toms and  the  absence  of  goiter  are  the  only  points  of  differ- 
entiation between  neurocirculatory  asthenia  and  hyper- 
thyroidism.  Many  observers  think  that  there  is  a  very 
close  relationship  between  these  conditions,  and  I  am 
inclined  to  believe  that  this  is  true.  In  the  majority  of 
cases,  however,  basal  metabolism  estimations  in  these 
patients  have  not  shown  an  increase  in  rate. 

Pulmonary  Tuberculosis. — Another  condition  which  must 
be  kept  in  mind  in  the  differential  diagnosis  of  hyperthy- 
roidism  is  pulmonary  tuberculosis.  Many  cases  of  early 
pulmonary  tuberculosis  do  not  show  any  very  definite 
evidence  in  the  lungs  and  may  complain  only  of  exhaustion 
and  an  increased  pulse-rate.  It  is,  therefore,  always  impor- 
tant in  making  a  diagnosis  of  what  appears  to  be  a  mild 
case  of  hyperthyroidism  to  be  on  the  lookout  for  pulmonary 
tuberculosis. 

Paroxysmal  Tachycardia. — Cases  of  paroxysmal  tachy- 
cardia, because  of  their  nervousness,  anxiety,  and  increased 
pulse-rate  may  be  confused  with  hyperthyroidism  when 
seen  for  the  first  time.  A  careful  history,  however,  will 
show  that,  except  for  some  shortness  of  breath,  the  patient 
has  been  in  normal  health,  and  that  the  onset  of  tachycardia 
has  been  very  sudden  and  the  return  to  the  normal  cardiac 
rate  equally  sudden.  However,  one  must  bear  in  mind  the 
fact  that  hyperthyroidism  is  often  complicated  by  attacks 
of  paroxysmal  tachycardia. 

MYXEDEMA 

Myxedema  may  be  congenital  in  origin,  in  which  case  it 
is  due  to  the  absence  of  the  thyroid  gland  (thyreo-aplasia) ; 


90  THE    THYROID    GLAND 

or  it  may  occur  late  in  life  as  the  result  of  a  deficiency  of 
thyroid  secretion  or  as  the  result  of  the  removal  of  too  much 
of  the  gland  at  operation. 

In  cases  of  congenital  myxedema  the  child  fails  to  develop 
mentally  or  physically.  The  head  is  brachy cephalic  in 
type  and  the  fontanels  remain  open.  The  child  has  a  dull, 


Fig.  23. — Congenital  myxedema.    Typical  case.    Child  aged  seven  years. 

heavy  appearance,  the  tissues  are  very  thick  and  dry,  the 
hair  is  scanty  and  dry,  there  is  a  sacculation  under  the 
eyelids,  the  face  is  swollen,  the  nose  broad  and  flat,  the  lips 
are  thick,  and  the  tongue  is  enlarged,  protruding  between 
the  lips  (Fig.  23).  The  voice  is  husky  and  coarse.  The 
abdomen  is  protuberant  and  there  is  a  tendency  to  umbilical 
hernia.  The  child  develops  very  slowly  mentally,  so  that 


DIFFERENTIAL    DIAGNOSIS    OF    DISEASES    OF    THYROID      91 

at  the  age  of  ten  he  may  not  be  any  further  advanced  than 
a  child  of  two.  The  extremities  are  short  and  the  hands 
are  thick  and  pudgy.  The  bones  ossify  very  slowly,  so  that 
the  ossification  of  the  bones  in  a  child  of  twelve  may  not 
be  any  farther  advanced  than  in  a  child  of  five.  In  the 
supraclavicular  regions  there  are  large  pads  of  fat.  The 
temperature  is  persistently  subnormal. 

This  condition  must  be  differentiated  from  Mongolian 
idiocy.  In  cases  of  Mongolian  idiocy  the  tissues  are  not 
thickened  as  much  as  in  myxedema;  the  tongue  is  not  as 
much  enlarged  and  does  not  protrude  so  far  between  the 
lips;  and  there  is  a  curious  slanting  of  the  eyes  downward 
and  inward  toward  the  nose,  which  is  absent  in  myxedema. 
In  Mongolian  idiocy  the  anteroposterior  diameter  of  the 
skull  is  very  much  decreased;  the  eyes  are  set  closely  to- 
gether, the  palpebral  fissure  is  narrow,  and  there  is  fre- 
quently epicanthus;  the  hands  of  the  Mongolian  idiot  are 
short  and  thick,  and  the  little  finger  is  so  short  that  often 
it  does  not  reach  to  the  last  interphalangeal  joint  of  the 
ring  finger.  Congenital  heart  disease  is  much  more  common 
in  the  Mongolian  idiot  than  in  cases  of  myxedema.  Relax- 
ation of  the  ligaments  of  the  joints  is  a  striking  feature, 
so  that  the  extremities  can  be  put  in  almost  any  position 
with  ease.  But  the  most  important  feature  in  the  differ- 
entiation between  congenital  myxedema  and  Mongolian 
idiocy  is  the  presence  or  absence  of  the  slanting  eyes 
described  above. 

Achondroplasia  is  another  condition  which  is  occasion- 
ally mistaken  for  cases  of  congenital  myxedema.  The 
characteristic  feature  of  this  disease  is  the  shortness  of  the 
arms  and  legs,  as  compared  with  the  length  of  the  body.  In 
cases  of  achondroplasia,  moreover,  the  intelligence  is  normal 
and  the  thyroid  gland  can  be  easily  palpated. 


92  THE   THYROID   GLAND 

In  adult  cases  of  myxedema,  which  are  found  more 
frequently  in  women  than  in  men  in  the  proportion  of  four  to 
one,  the  most  striking  symptoms  are  a  feeling  of  chilliness,  a 
tendency[~,to  drowsiness,  increase  in  weight,  dryness  of  the 
skin,  loss  of  hair,  and  change  in  the  voice.  The  subcutaneous 
tissues  are  very  thick  and  the  patient's  weight  is  increased. 
The  facial  features  are  greatly  altered.  The  lines  of  ex- 
pression of  the  face  are  gone,  the  eyes  are  dull  and  heavy* 
there  is  sacculation  under  the  eyes,  the  nostrils  are  broad 
and  thick,  the  lips  are  thickened,  and  the  voice  is  husky. 
Pads  of  fat  are  present  in  the  supraclavicular  region. 
Although  there  appears  to  be  a  swelling  of  the  subcutaneous 
tissue,  it  will  not  pit  on  pressure.  The  temperature  is 
subnormal,  and  the  basal  metabolism  rate  is  from  20  to  40 
per  cent,  below  normal.  There  is  an  increased  tolerance  to 
carbohydrates.  The  memory  is  defective;  the  patients  are 
often  irritable  and  suspicious;  and  in  some  instances  they 
pass  into  a  condition  of  dementia.  The  thyroid  is  dimin- 
ished in  size  and  may  become  completely  atrophied.  These 
patients  show  a  tendency  to  arteriosclerosis  with  arterial 
hypertension  and  myocardial  degeneration.  With  the 
dryness  of  the  skin  there  is  almost  complete  absence  of 
perspiration  and  the  sensation  of  touch  is  impaired. 
Patients  with  myxedema  often  complain  of  rheumatic  pains 
in  various  parts  of  the  body.  The  hands  and  feet  are 
thick  and  clumsy,  the  fingers  are  enlarged  and  lose  their 
dexterity.  To  this  condition  of  the  hands  Gull  has  aptly 
applied  the  term  "spade  hands."  Menstruation  is  often 
suppressed  and  there  is  a  diminution  in  the  sexual  desires 
of  both  sexes.  The  blood  shows  a  diminution  in  the  number 
of  red  corpuscles  and  a  correspondingly  greater  reduction  in 
the  hemoglobin.  The  white  cells  show  a  leukopenia  and  a 
hyperlymphocytosis. 


DIFFERENTIAL   DIAGNOSIS    OF   DISEASES    OF    THYROID      93 

Because  of  the  anemia  cases  of  myxedema  have  some- 
times been  incorrectly  diagnosed  as  pernicious  anemia.  In 
the  latter  condition,  however,  there  is  no  infiltration  of  the 
subcutaneous  tissue,  and  the  blood  findings  serve  to  estab- 
lish the  differentiation.  In  pernicious  anemia  the  color 
index  is  high,  the  anemia  is  more  marked,  the  presence  of 
nucleated  red  corpuscles  and  the  characteristic  changes 
in  size,  shape,  and  staining  properties  of  the  red  cells  make 
the  diagnosis  easy.  Moreover,  in  pernicious  anemia  patho- 
logic changes  in  the  central  nervous  system,  with  the  char- 
acteristic symptoms  and  physical  signs,  are  found  in  70  per 
cent,  of  the  cases. 

The  infiltration  of  the  tissues  in  myxedema  has  led  this 
condition  to  be  incorrectly  diagnosed  as  nephritis.  In  the 
latter  disease  the  tissues  pit  on  pressure,  and  if  there  is 
much  edema  fluid  accumulates  in  the  serous  sacs.  The 
urinary  findings  together  with  functional  kidney  tests  will 
render  the  diagnosis  clear. 

Hypopituitarism. — Cases  of  hypopituitarism  are  some- 
tunes  incorrectly  diagnosed  as  myxedema.  I  have  seen  two 
instances  of  this  error  in  diagnosis  within  the  past  six 
months.  One  of  these  cases,  a  young  man  twenty-two  years 
of  age,  is  shown  in  Fig.  24.  In  hypopituitarism  the  skin  is 
soft,  the  body  practically  hairless.  In  the  male  the  distri- 
bution of  the  pubic  hair  when  present  resembles  that  of 
the  female,  the  sexual  organs  are  imperfectly  developed, 
and  the  configuration  of  the  body  and  the  development  of 
the  breasts  resemble  those  of  the  female.  The  voice  is 
high  pitched.  The  fingers  are  long  and  tapering.  In  cases 
of  hypopituitarism  various  grades  of  enlargement  of  the 
sella  turcica  are  seen  and  bitemporal  hemianopsia  may  be 
present. 


94 


THE    THYROID    GLAND 


Fig.  24. — Typical  case  of  infantilism  due  to  hypopituitarism.  Note  lack 
of  hair  on  axilla  and  on  pubes,  characteristic  form  of  hand,  female  contour. 
Patient  aged  twenty-two. 

TUMORS  OF  THE  THYROID 

Tumors  of  the  thyroid  may  be  benign  or  malignant, 
and  usually  develop  in  a  pre-existing  goiter.  Of  the  benign 
tumors,  the  most  common  are  the  adenomata,  which  we 
have  described  above;  such  growths  as  fibromata,  lipomata, 
and  echinococcus  cysts  being  so  rare  as  not  to  warrant  much 
consideration.  Occasionally  adenomata  may  become  malig- 
nant. The  most  important  malignant  tumors  are  the  carci- 
nomata.  They  are  found  much  more  frequently  than  the 
sarcomata.  Malignant  tumors  of  the  thyroid  invade  the 


DIFFERENTIAL    DIAGNOSIS    OF    DISEASES    OF    THYROID       95 

capsule  so  that  it  becomes  adherent  to  the  surrounding 
structures.  The  trachea  and  the  esophagus  may  be  invaded 
and  compressed.  The  carotid  artery  may  be  displaced  and 
the  carotid  sheath  may  become  adherent  to  the  tumor  mass. 
The  walls  of  the  veins  are  less  resistant  than  the  walls  of 
the  arteries  to  the  invasion  of  the  tumor,  so  that  thrombosis 
often  occurs.  There  may  be  pressure  on  the  recurrent 
laryngeal,  vagus  and  sympathetic  nerves,  and  the  upper 
roots  of  the  brachial  plexus.  Metastases  may  occur  in  any 


Fig.  25. — External  appearance  of  malignant  goiter. 


organ.  In  one  case  that  I  saw  some  years  ago  at  autopsy 
metastases  from  a  carcinoma  of  the  thyroid  were  found  in 
the  pituitary  gland  and  in  the  lungs. 

A  malignant  tumor  of  the  thyroid  should  always  be 
suspected  when  a  goiter  begins  to  enlarge  quite  rapidly,  and 
especially  if  it  is  painful  and  is  adherent  to  the  surrounding 
skin  (Figs.  25,  26).  Sometimes  the  pain  is  quite  severe  and 
may  be  referred  to  the  shoulder  because  of  pressure  on  the 
brachial  plexus.  Interference  with  deglutition  and  difficulty 


96 


THE    THYROID    GLAND 


in  breathing  are  caused  by  the  pressure  on  the  esophagus 
and  trachea.  The  voice  is  hoarse  and  there  may  be  aphonia. 
The  veins  of  the  neck  may  be  greatly  congested  and  edema 
of  the  face  and  cyanosis  may  be  present.  The  skin  is  red- 
dened and  in  rare  cases  may  become  ulcerated.  If  the  sym- 
pathetic nerve  in  the  neck  is  compressed  there  may  be  a 


Fig.  26. — External  appearance  of  malignant  goiter. 

slight  exophthalmos,  miosis,  and  loss  of  pupil  reaction.  In 
the  late  stages  of  the  disease  ulceration  into  the  trachea 
and  esophagus,  with  resulting  hemorrhage,  may  occur. 
The  patient  shows  rapid  emaciation  and  cachexia,  and  a 
remittent  fever  is  not  uncommon.  Death  occurs  from 
exhaustion  or  from  pneumonia. 

INFLAMMATION   OF   THE   THYROID   GLAND   (THYROIDITIS    OR 

STRUMITIS) 

An  inflammatory  condition  of  the  thyroid  gland  may 
occur  during  the  course  of  an  acute  disease,  such  as  typhoid 
fever  or  influenza,  or  it  may  be  more  chronic  in  character 
as  the  result  of  a  tuberculous  or  syphilitic  infection.  In  the 


DIFFERENTIAL   DIAGNOSIS   OF   DISEASES   OF   THYROID      97 

acute  cases  the  onset  of  the  disease  is  sudden  and  is  ushered 
in  by  chills  and  fever.  There  is  intense  pain  in  the  neck 
which  is  referred  to  the  occiput,  the  ear,  or  down  the  arm. 
A  sense  of  constriction  of  the  neck  and  difficulty  in  breath- 
ing is  complained  of  in  the  majority  of  cases.  Very  soon  the 
thyroid  is  swollen,  hot,  and  tender.  The  tenderness  and 
pain  in  the  gland  is  increased  by  swallowing  or  by  move- 
ments of  the  head  and  neck.  Sometimes  there  is  an  accom- 
panying tracheitis  with  hoarseness  and  cough,  and  occasion- 
ally aphonia.  In  these  cases  alarming  suffocative  attacks 
may  occur.  If  suppuration  occurs  the  skin  over  the  gland 
becomes  reddened.  I  saw  one  such  case  a  year  ago  in  a  man 
forty-five  years  of  age  who  had  typhoid  fever.  He  had 
always  had  a  goiter  and  the  right  lobe  of  the  thyroid  con- 
tained a  cystadenoma  about  the  size  of  a  hen's  egg.  During 
the  fourth  week  of  the  disease  this  became  painful  and  tender, 
increased  considerably  in  size,  and  the  skin  became  red- 
dened. On  the  tenth  day  after  the  onset  of  the  strumitis 
an  incision  was  made  and  six  ounces  of  pus  evacuated. 
The  inflammation  quickly  subsided  and  the  patient  made  a 
good  recovery. 

A  rare  form  of  thyroiditis,  which  has  been  termed 
"woody  thyroiditis,"  was  first  described  in  1896  by  Riedel. 
The  gland  is  hard  and  firm,  resembling  a  malignant  tumor, 
and  the  most  striking  symptoms  are  pain  and  dyspnea. 
Bacteriologically  the  cause  of  the  condition  has  not  been 
determined.  It  may  cause  all  the  symptoms  and  physical 
signs  from  pressure  on  the  surrounding  structures  that  have 
been  described  under  colloid  goiter.  Though  rare,  it  is 
important  to  remember  that  such  a  condition  exists  because 
it  is  not  infrequently  mistaken  for  malignant  tumor. 


ADRENALIN  SENSITIZATION  TEST  FOR 
HYPERTHYROIDISM 

ROBERT  S.  DINSMORE 


THE  adrenalin  sensitization  test1  is  based  on  the  observa- 
tion that  in  cases  of  hyperthyroidism  there  is  a  constitu- 
tional hypersensitiveness  to  the  injection  of  adrenalin 
chlorid.  Dr.  Goetsch  used  the  test  to  establish  a  differential 
diagnosis  between  hyperthyroidism  and  early  tuberculosis 
in  patients  presenting  the  syndrome  of  loss  of  weight  and 
strength,  fatigue,  and  slight  elevation  of  temperature,  in 
whom  the  physical  signs  and  x-ray  findings  for  tuberculosis 
were  negative. 

The  test  is  not  made  until  the  patient  has  been  in  the 
hospital  for  at  least  twenty-four  hours  and  has  become  thor- 
oughly accustomed  to  his  new  surroundings.  It  is  essential 
that  the  normal  readings  be  obtained  while  the  patient  is 
quiet  and  calm.  Six  minims  of  adrenalin  chlorid,  1  :  1000, 
are  injected  subcutaneously  with  a  tuberculin  syringe.  In 
cases  of  severe  exophthalmic  goiter  the  Goetsch  test  is  not 
only  unnecessary,  but  is  unsafe  as  well.  As  a  rule  patients 
with  a  blood-pressure  above  160  are  not  subjected  to  the 
test. 

Observations  are  made  at  five-minute  intervals  and 
include  the  following: 

1.  Blood-pressure. 

2.  Pulse-rate. 

3.  Respiration  rate. 

1  Goetsch,  E.,  N.  Y.  State  Med.  Jour.,  1918,  xviii,  259. 
99 


100  THE   THYROID   GLAND 

4.  Nervousness. 

5.  Tremor  of  fingers. 

6.  Hyperhydrosis. 

7.  Size  of  pupils. 

8.  Pallor  or  flushing  of  skin. 

If,  before  the  adrenalin  is  injected,  the  patient  becomes 
excited  or  frightened,  it  is  advisable  to  discontinue  the  test  at 
once.  The  observations  and  readings  are  continued  for  from 
forty  minutes  to  one  hour  or  longer  if  the  reaction  persists. 
At  the  completion  of  the  test  the  patient  is  asked  for  his 
subjective  symptoms,  which  are  also  recorded  on  the  chart. 
The  results  of  the  reaction  are  recorded  as  either  negative, 
slight,  positive,  or  marked. 

We  have  made  Goetsch  tests  on  251  patients.  In  213 
of  these,  89  per  cent.,  there  were  positive  reactions  of  varying 
degrees.  In  the  remaining  11  per  cent,  the  reaction  was 
negative. 

The  average  increase  in  blood-pressure  in  the  entire 
group  was  eighteen.  Some  of  the  patients  showed  no  in- 
crease in  blood-pressure,  but  increased  tremor,  nervousness, 
and  hyperhydrosis.  The  highest  increase  in  blood-pressure 
was  in  a  patient  with  a  blood-pressure  of  168  mm.,  which, 
following  an  injection  of  four  minims  of  adrenalin,  was  in- 
creased to  260  mm.,  an  increase  of  92  mm.  Another  patient 
showed  an  increase  of  74  mm.,  the  blood-pressure  rising 
from  138  to  212. 

Pallor  was  noted  only  in  severe  reactions,  occurring  in 
about  11  per  cent,  of  the  cases.  Sweating  was  more  fre- 
quent. Pallor  is  probably  the  most  difficult  objective 
symptom  to  interpret,  and  little  reliance  can  be  placed 
upon  it  as  a  positive  symptom.  Tremor  occurred  in  204, 
or  81  per  cent.,  of  the  patients  tested.  Nervousness  as  an 
objective  symptom  occurred  less  frequently,  only  147  of 


ADKENALIN   TEST   FOR   HYPERTHYROIDISM  101 

the  cases,  or  58  per  cent.,  displaying  an  increased  objective 
nervousness.  If  the  subjective  nervousness  of  which  the 
patients  complain  so  frequently  at  the  completion  of  the 
test  were  included  the  percentage  would  be  slightly  higher. 
Comparing  the  results  of  basal  metabolism  measurements 
with  the  results  of  the  Goetsch  test,  we  find  them  in  accord 
in  about  80  per  cent,  of  the  cases.  Among  a  group  of 
patients  with  metabolism  more  than  20  per  cent,  above 
the  normal  the  Goetsch  test  was  positive  hi  85  per  cent. 
We  had  hoped  that  the  Goetsch  test  and  metabolism  would 
give  us  a  means  whereby  to  estimate  the  operability  of  our 
patients.  While  it  is  true  that  a  large  percentage  of  patients 
with  a  very  greatly  increased  metabolism  and  a  marked 
reaction  to  adrenalin  would  probably  show  marked  post- 
operative reaction,  the  following  observations  show  that 
one  cannot,  with  accuracy,  predict  the  severity  of  the 
postoperative  reaction. 

Case  I.      Metabolism  increase,  75  per  cent. ; 

Goetsch  test  positive; 

Postoperative  reaction  slight. 
Case  II.     Metabolism  increase,  19  per  cent.; 

Goetsch  test  negative; 

Postoperative  reaction  moderately  severe. 
Case  III.  Metabolism  increase,  82  per  cent.  ; 

Goetsch  test  positive; 

Postoperative  reaction,  none. 

A  total  of  sixty-five  Goetsch  tests  have  been  made  in 
patients  with  adenomata.  In  forty-one  of  these  the  test 
was  entirely  negative,  and  it  was  definitely  positive  in  only 
eight.  In  only  one  of  the  sixty-five  cases  was  there  a  severe 
postoperative  reaction  with  dementia.  In  all  the  other  cases 
there  was  no,  or  a  very  slight,  postoperative  reaction.  In 
these  patients  the  basal  metabolism  was  normal. 


102  THE    THYROID    GLAND 

Practically  no  difference  can  be  noted  between  the  post- 
operative reaction  in  patients  with  a  slight  positive  reaction 
to  adrenalin  and  that  in  those  with  a  negative  reaction. 

SUBJECTIVE  SYMPTOMS 

Among  the  interesting  aspects  of  the  Goetsch  test  are 
the  subjective  symptoms  of  the  patients.  Some  of  these 
should  certainly  be  discounted.  Some  patients  become 
frightened,  restless,  and  cry  immediately  after  the  hypo- 
dermic injection.  This  response  can  always,  however,  be 
easily  differentiated  from  the  reaction  to  the  adrenalin. 

Among  the  more  common  complaints  are  pain  in  the 
chest  and  neck,  various  cardiac  symptoms,  nervousness, 
and  a  feeling  of  warmth  or  of  cold.  Some  patients  exhibit 
a  distinct  reaction  with  no  complaint.  The  verbal  expres- 
sions of  the  patients  best  describe  their  subjective  symptoms: 

"Body  shaking,"  "I  feel  hot,"  "My  feet  are  sweating," 
"My  back  is  hot,"  "Heart  pounded,"  "Nervous  and  trem- 
bly," "Throbbing  in  ears"  (one  case  only),  "Choked  up 
sensation  in  neck,"  ' 'Heart  beating  better,"  "Heart  thump- 
ing," "Heart  beating  hard,"  "Heart  jumping,"  "Short  of 
breath,"  "One  of  my  normal  attacks,"  "Chilly,"  "That 
medicine  you  gave  me  has  effected  my  heart,"  "Headache," 
"I  feel  a  thud  in  my  heart,"  "Like  overloading  the  stomach/' 
"Pressure  against  eyes,"  "Shaky,"  "Like  a  current  of  elec- 
tricity through  the  body,"  "Choking,"  "Weak  and  trembly," 
"Backache,"  "Heart  missing  a  beat,"  "I  feel  weak  and  my 
heart  is  beating  so  fast,"  "Pinching  sensation  in  left  side," 
"My  heart  is  beating  much  stronger  and  shakes  my  body/' 
"I  feel  so  nervous,"  "My  heart  is  beating  faster,"  "My 
heart  is  pounding,"  "Feel  as  if  my  heart  was  all  over  me," 
"Every  beat  goes  to  the  end  of  my  toes,"  "Something  is 
making  my  heart  thump,"  "I  feel  better." 


ADRENALIN   TEST   FOR   HYPERTHYROIDISM  103 

CONCLUSIONS 

1.  The  Goetsch  test  has  been  of  distinct  value  to  us  in 
the  differentiation  of  borderline  cases  of  hyperthyroidism. 

2.  Eighty-nine  per  cent,   of  the  patients  with  clinical 
symptoms  of  hyperthyroidism  give  a  positive  reaction  to 
adrenalin. 

3.  In  about  85  per  cent,  of  the  cases  the  results  of  the 
Goetsch  test  are  in  agreement  with  the  metabolism   esti- 
mations.   (Basal  metabolism  estimations  themselves  are  dis- 
tinctly less  than  100  per  cent,  accurate.) 

4.  The  results  of  the  reaction  to  adrenalin  cannot  be 
used  as  a  basis  for  estimating  the  operability  or  postoperative 
reaction  of  a  patient.    In  this  respect  the  Goetsch  test  can 
never  supplant  clinical  experience  with  large  numbers  of 
patients  with  hyperthyroidism. 


A  SERUM  TEST  FOR  EXOPHTHALMIC  GOITER 

FRANK  D'HOUBLER 


THE  test  described  below  was  devised  by  Dr.  Kurt 
Kottman,  of  Berne,  Switzerland,  who,  after  trying  it  in  a 
number  of  cases,  believes  that  it  is  a  valuable  diagnostic 
means  for  the  detection  of  either  hyper-  or  hypothyroidism.i 
The  writer  is  greatly  indebted  to  Dr.  Kottman  for  his  per- 
sonal demonstration  of  the  technic  of  this  method. 

TECHNIC 

Blood  is  withdrawn  from  a  patient  by  the  same  method 
as  that  employed  for  a  Wassermann  test.  In  order  to  secure 
reliable  end-results  care  must  be  observed  that  the  patient 
has  not  tasted  food  within  twelve  hours  or  used  medicine 
containing  bromin  within  two  months  of  the  withdrawal  of 
the  blood,  and  the  test  must  be  performed  soon  after  the 
blood  has  been  taken. 

The  blood  is  centrifuged,  and  to  1  c.c.  of  the  clear  serum 
are  added  0.5  c.c.  of  potassium  iodid  solution  (£  per  cent.) 
and  0.6  c.c.  silver  nitrate  solution  (|  per  cent.).  This 
part  of  the  test  is  performed  in  a  dark  room  with  a  red 
light.  The  resulting  whitish  opaque  fluid  is  thoroughly 
mixed  by  drawing  it  up  into  a  pipet  and  allowing  it  to  flow 
back  into  the  containing  tube.  This  mixing  must  be  done 
very  carefully  so  as  not  to  produce  bubbles  or  foam.  The 
small  glass  test-tubes  used  in  determining  Wassermann  re- 
actions are  suitable  for  the  test.  The  blood-serum  from  a 
normal  individual  is  used  as  a  control. 

1  Kottman,  Karl,  Schweiz.  Med.  Wochensch.,  1920, 1,  644. 
105 


106  THE    THYROID   GLAND 

The  tubes  containing  the  serum-potassium-iodid-silver 
nitrate  mixture  (from  now  on  to  be  regarded  as  colloidal 
suspension  of  silver  iodid)  are  exposed  for  fifteen  minutes 
to  a  500  candle-power  light  at  a  distance  of  25  cm.  Then, 
under  a  red  light,  1  c.c.  of  hydrochinon  (f  per  cent.)  solution 
is  added  to  each  tube.  The  sera  from  hypothyroid  cases 
is  the  first  to  assume  a  reddish-brown  tinge,  which  soon 
turns  to  a  deeper  shade.  Normal  sera  show  color  and  the 
deepening  of  color  more  slowly  than  the  hypothyroid  sera. 
In  the  sera  from  hyperthyroid  cases  color  appearance  and 
development  are  manifested  most  slowly. 

The  time  relations  between  hypothyroid,  normal,  and 
hyperthyroid  reactions  depend  in  part  upon  the  amount 
of  light  exposure.  In  our  own  experience  the  light  used 
exceeds  500  candle-power  and  has  to  be  removed  to  120 
cm.  and  the  time  is  reduced  to  twelve  minutes.  By  this 
arrangement  the  normal  reaction  appears  within  five  min- 
utes, while  the  hyperthyroid  reaction  usually  shows  color 
only  after  thirty  minutes  or  more.  In  less  strongly  positive 
cases  the  time  difference  is  less,  but  sufficient  for  sharp 
differentiation.  Any  one  employing  the  test  will  do  well 
to  vary  the  distance  of  the  light  to  find  what  is  best  with 
the  lamp  he  is  using.  The  technic  is  readily  mastered  and 
the  differences  in  the  reactions  are  so  clear  cut  that  the 
determination  of  the  result  is  extremely  easy. 

THEORY 

The  theory  on  which  this  test  is  based  is  in  accordance 
with  the  principles  of  colloidal  chemistry.  One  colloid  is 
able  to  influence  the  state  of  another  colloid,  and  often 
through  protective  action  makes  possible  a  colloidal  sus- 
pension of  a  substance  which  in  water  would  not  be  stable. 
The  human  serum  is  a  colloid  and  is  able  to  cause  the  diffi- 


A    SERUM    TEST    FOR    EXOPHTHALMIC    GOITER  107 

cultly  soluble  silver  iodid,  resulting  from  the  potassium  iodid 
and  silver  nitrate,  to  remain  in  colloidal  suspension.  This 
explains  the  opaque  whitish  color  of  the  primary  mixture. 
To  be  brief,  this  protective  quality  varies  in  different  sera, 
and  is  stronger  in  hyperthyroid  serum  than  in  normal  serum; 
and  in  hypothyroid  serum  is  weaker  than  in  normal  serum. 
In  other  words,  the  fineness  of  suspension  of  the  silver  iodid 
is  greatest  under  the  influence  of  serum  from  a  case  of  hyper- 
thyroidism  and  least  under  the  influence  of  serum  from  a 
case  of  hypothyroidism,  while  the  normal  serum  effects  an 
intermediary  reaction.  Further,  a  substance,  such  as  silver 
iodid,  which  is  sensitive  to  light,  is  less  sensitive  in  a  fine 
colloidal  suspension  than  in  a  coarse  suspension. 

It  is  now  evident  why,  after  the  addition  of  hydrochinon, 
we  find  different  reaction  times  in  the  various  tubes  contain- 
ing different  sera.  The  hydrochinon  is  simply  a  developer. 
The  light  has  caused  a  reduction  of  silver  iodid  to  subiodid 
and  the  hydrochinon  completes  the  reduction  to  metallic 

silver. 

PRACTICAL  APPLICATION 

We  have  tested  fifty-eight  clearly  defined  cases  of  ex- 
ophthalmic goiter,  trying  to  avoid  patients  who  had  been 
taking  bromids.  Of  these,  fifty-seven  gave  positive  results 
and,  strangely  enough,  one  severe  case  reacted  as  a  case  of 
hypothyroidism.  Of  fifteen  borderline  cases  (some  with 
normal  metabolism),  fourteen  were  positive  and  one  reacted 
normally.  Three  goiter  cases,  without  definite  exophthalmic 
goiter  symptoms  and  signs,  were  tested.  Two  of  these  re- 
acted as  mildly  hypothyroid  cases  and  one  gave  a  normal 
reaction.  Twenty  ' 'normal"  individuals  have  been  tested 
with  consistent  results.  These  were  mostly  patients  tested 
before  operation,  and  included  among  them  were  cases  of 
hernia  and  gastric  ulcer  and  other  non-thyroid  conditions. 


THE  ROLE  PLAYED  BY  THE  RADIOLOGIST  IN  THE 
DIAGNOSIS  OF  GOITER 


BERNARD  H.  NICHOLS 


THE  type  of  goiter  in  which  the  radiologist  becomes  of 
the  greatest  assistance  in  diagnosis  is  the  so-called  intra- 


Fig.   27. — Schematic  drawings  illustrating  different  types  of  compression  of 
trachea  produced  by  goiter. 

thoracic  or  substernal  type,   which  includes  those  goiters 
which  lie  wholly  or  partially  within  the  thoracic  cavity.  There 

109 


110 


THE    THYROID    GLAND 


are  goiters  whose  pole  may  project  into  the  upper  portion 
of  the  thorax,  but  for  so  short  a  distance  as  to  give  rise  to 
no  resultant  symptoms.  These  should  not  be  classified  as 
intrathoracic  in  character  in  reporting  the  findings  of  a 
radiographic  examination  of  the  chest.  Kocher  refers  to 
goiters  of  this  type  as  "struma  profunda,"  or  deep  goiter. 


Fig.  28. — Schematic  drawings  illustrating  different  types  of  compression  of 
trachea  produced  by  goiter. 

A  consideration  of  the  development  of  intrathoracic 
goiter  may  be  of  considerable  aid  in  the  diagnosis.  Intra- 
thoracic goiter  may  develop  from  the  isthmus  or  one  of  the 
lower  poles  of  the  thyroid  or  from  an  intrathoracic  acces- 
sory lobe;  but  the  larger  percentage  of  cases  undoubtedly 
develop  from  a  pre-existing  goiter  which  gradually  extends 


into  the  thoracic  cavity.     The  origin  of  an  intrathoracic 
goiter  can  usually  be  determined  by  the  position  of  the 


TOP      VIEW 


SECTION    OP      TtCACWEA 


Fig.  29. — Encircling  goiter  with  posterior  compression  of  the  trachea. 

trachea  as  it  appears  in   the  radiograph.     For  example, 
development  from  the  right  lobe  alone  will  usually  displace 


112 


THE   THYROID   GLAND 


Fig.  30. — Partially  intrathoracic  median  spiral  goiter  with  anterior  pressure 

on  trachea. 


Fig.  31. — Intrathoracic  bilateral  goiter  with  bilateral  pressure  on  trachea. 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       113 

the  trachea  to  the  left  of  the  median  line;  while,  if  the 
growth  is  from  the  left  lobe,  the  opposite  condition  will  be 
present.  If  the  growth  extends  from  both  lobes,  but  is 
more  extensive  on  one  side  than  on  the  other,  there  results 
an  irregular  compression  of  the  trachea  somewhat  simulating 
the  letter  S.  If  both  lobes  have  developed  about  equally 


Fig.  32. — Partially  intrathoracic  goiter. 

there  results  a  double  compression  of  the  trachea  producing 
the  so-called  "saber-sheath"  trachea.  If  the  enlargement 
originates  in  the  isthmus,  the  trachea  may  be  compressed 
and  the  shadow  obliterated  (Figs.  27-32). 

Since  the  trachea  is  an  air-filled  organ  located  in  the 
mediastinum  where  the  surrounding  structures  are  of 
greater  density  than  air,  the  tracheal  position  is  usually 


114 


THE    THYROID    GLAND 


easily  identified  on  a  radiograph,  and  any  displacement  or 
abnormality  in  shape  at  once  attracts  attention. 

METHODS  OF  EXAMINATION 

The  examination  of  the  chest  for  intrathoracic  goiter 
should  be  made  both  by  radiograph  and  by  fluoroscope,  as 


Fig.  33. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  showing 
compression  of  trachea  by  goiter  and  aortitis. 

each  of  these  methods  contributes  important  points  to  the 
diagnosis. 

Stereoscopic     anteroposterior     radiographs     should     be 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS    OF   GOITER       115 

made,  the  plate  being  placed  against  the  anterior  chest 
wall,  with  the  patient  in  either  a  standing  or  reclining 
position.  The  second  oblique  position  is  often  of  value,  for 
from  this  position  it  is  possible  to  study  the  retrocardiac 


Fig.  34. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  intra- 
thoracic  goiter  showing  displacement  of  trachea  toward  the  left. 

space  in  the  case  of  a  goiter  developed  from  the  isthmus  and 
to  determine  whether  or  not  the  trachea  is  compressed. 

The  importance  of  the  radiograph  lies  in  the  fact  that  it 
tends  to  bring  out  the  sharpness  and  regularity  of  outline 
of  the  shadow  as  well  as  the  position  and  deformity  of  the 
trachea.  It  also  acts  as  a  permanent  record  and  guides  the 


116 


THE   THYROID    GLAND 


surgeon  at  the  time  of  operation  in  determining  the  location 
and  extent  of  the  tumor. 

For  the  fluoroscopic  examination  the  patient  is  best 
examined  in  the  upright  position.  The  patient  should 
first  face  the  screen  and  then  be  rotated  to  the  most  advan- 


Fig.  35. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  in- 

trathoracic  goiter. 


tageous  position  for  a  good  view  of  the  mediastinum.  This 
may  prove  to  be  either  the  first  or  second  oblique  position, 
or  the  reverse  position  with  the  patient's  back  to  the  screen. 
In  this  manner  we  may  determine  many  points  in  the  diag- 
nosis which  are  not  elicited  by  radiographs.  The  most 


ROLE   OF  RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       117 

important  of  these  are  the  behavior  of  the  mediastinal 
shadow  during  the  normal  heart  and  vascular  activities, 
during  deglutition  and  during  deep  inspiration  and  expira- 
tion; the  size  and  position  of  the  heart;  the  excursion  and 
position  of  the  diaphragm  on  either  side;  the  appearance  of 


Fig.  36. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  intra- 
thoracic  goiter  showing  saber-sheath  trachea. 

the  retro-cardiac  space;  and  the  size,  shape,  and  position  of 
the  esophagus  after  the  ingestion  of  a  barium  mixture. 

The  abnormalities  which  may  be  found  in  the  upper 
thoracic  cavity  become  of  diagnostic  interest  to  us  in  con- 
nection with  the  study  of  intrathoracic  goiters,  as  many  of 


118 


THE    THYROID    GLAND 


these  give  definite  clinical  symptoms,   which  require  the 
radiologic  findings  for  their  differential  diagnosis. 

An  intrathoracic  goiter  shadow  usually  lies  high  in  the 
mediastinum  and  appears  as  a  continuation  of  the  supra  - 
clavicular  shadow.  The  outline  is  regular  in  cases  which 


Fig.  37. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  intra- 
thoracic goiter. 

are  not  nodular  or  malignant  in  character  and  is  usually 
silhouetted  over  the  pneumonic  cavity  of  the  lung  on  one 
or  both  sides  of  the  mediastinum  (Figs.  33-38). 

The  fluoroscopic  image  of  an  intrathoracic  goiter  usually 
appears  as  a  dense  shadow  in  the  upper  mediastinum,  and 


ROLE    OF    RADIOLOGIST    IN    DIAGNOSIS    OF    GOITER       119 

in  the  case  of  an  extension  from  the  supraclavicular  goiter 
it  broadens  out  above  to  join  the  tumor  in  the  neck.  The 
outline  is  regular  and  may  be  seen  to  move  up  and  down 
during  deglutition  or  on  deep  inspiration  or  expiration.  If 


Fig.  38. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  intra- 
thoracic  goiter  with  marked  displacement  of  trachea. 

there  is  pressure  on  the  vessels  the  tumor  may  have  the 
appearance  of  pulsating.  This  apperaance,  however,  is  due 
to  a  transmitted  impulse  and  is  not  expansile  in  character. 
From  stereoscopic  plates  of  the  chest  in  the  postero- 
anterior  position  we  may  study  the  outline  of  the  tumor  to 


120 


THE    THYROID    GLAND 


a  better  advantage  and  may  also  determine  the  presence  of 
any  compression  or  displacement  of  the  trachea. 

A  goiter  does  not  usually  cast  as  dense  a  shadow  as  the 
heart  and  great  vessels,  thus  the  latter  may  often  be  dis- 


Fig.    39. — Differential    diagnosis    of    intrathoracic    goiter.      Radiograph    of 

aortic  aneurysm. 

cerned  through  the  goiter  shadow.  The  shadow  of  the  ves- 
sels may  be  seen  to  continue  down  directly  from  a  supra- 
clavicular  goiter. 

The  nodular  carcinomatous  type  of  intrathoracic  goiter 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       121 

offers  the  greatest  difficulty  in  diagnosis,  and  the  clinical 
symptoms,  as  well  as  the  physical  examination,  may  be 
necessary  in  addition  to  the  fluoroscopic  examination  to 
confirm  the  diagnosis. 

In  all  mediastinal  work  we  get  the  best  results  from  very 


Fig.  40. — Differential  diagnosis  of  in tra thoracic  goiter.    Radiograph  of  aortic 

aneurysm. 

rapid  exposure  with  duplitized  films,  and  feel  that  nowhere 
is  it  so  important  to  use  a  short  exposure  as  in  radiographing 
the  mediastinum. 

Every  roentgenologist  is  familiar  with  the  excursion  of 
the  mediastinal  shadow  during  the  pulsation  of  the  heart 


122  THE    THYROID    GLAND 

and  adjacent  vessels  which  moves  the  bronchi  and  sup- 
porting tissues  to  a  varied  extent  in  different  individuals,  so 
that  from  a  three-  or  four-second  plate  of  the  chest  one  may 
often  make  an  erroneous  diagnosis  of  peribronchial  thick- 
ening at  the  hilus  or  entertain  a  suspicion  of  mediastinitis. 


Fig.  41. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  aortic 
aneurysm  with  trachea  displaced  to  right. 

Thoracic  aneurysm  is  perhaps  one  of  the  most  important 
pathologic  conditions  in  the  upper  thorax  with  which  we 
have  to  deal  in  the  differential  diagnosis  of  intrathoracic 
goiter.  The  aneurysm,  as  seen  on  the  radiograph,  is  a 
clean-cut  shadow,  regular  in  outline,  and  may  appear  as 
a  distinct  bulging  or  expansion  of  the  aorta  or  great  vessels 


ROLE    OF    RADIOLOGIST    IN    DIAGNOSIS    OF    GOITER       123 

of  the  thorax.  From  the  radiograph  we  may  study  the 
cardiac  displacement  and  also  the  displacement  of  the 
trachea,  but  the  most  valuable  information  is  obtained  by 
fluoroscopic  examination. 

The  diagnostic  sign  of  aneurysm  is  a  distinct  expansile 
pulsation  which  does  not  allow  the  tumor  to  recede  to  its 
normal  size  between  pulsations. 

There  is  a  distinct  angle  between  the  aortic  shadow  and 
that  of  an  intrathoracic  goiter.  This  angle  is  seen  to  change 
during  deglutition  and  deep  inspiration,  due  to  the  rising 
and  falling  of  the  intrathoracic  goiter.  This  is  almost 
diagnostic  of  thoracic  goiter  and  distinguishes  it  from 
aneurysm.1  By  careful  radiographic  and  fluoroscopic  exam- 
ination little  difficulty  should  be  experienced  in  determining 
the  presence  of  an  aneurysm  (Figs.  39-41). 

A  dilated  or  elongated  aorta  has  often  to  be  considered, 
and  the  transverse  position  of  the  heart,  which  is  so  aptly 
described  by  Thomas,  is  well  established  in  the  study  of 
these  cases  (Figs.  42,  43).  Fluoroscopic  examinations 
demonstrate  an  expansile  pulsation  of  these  tumefactions 
which  recede  during  pulsation  to  the  size  of  the  normal 
vessel.2 

A  thymus  tumor  is  usually  lower  in  the  chest  and  over- 
shadows the  heart.  The  mass  is  triangular  in  shape  and  an 
oblique  fluoroscopic  study  discloses  it  well  anterior  in  the 
chest  (Figs.  44,  45).  The  majority  of  thymus  tumors  occur 
in  children,  but  occasionally  a  persistent  thymus  is  encoun- 
tered which  offers  a  grave  complication  in  goiter  cases.  For 
this  condition  deep  radiotherapy  is  indicated,  by  means  of 
which  very  striking  results  in  the  reduction  of  the  thymus 
may  be  secured. 

1  Crotti,  Andre,  J.  A.  M.  A.,  1913,  Ix,  117. 

2  Thomas,  George  F.,  Am.  J.  Roentgenol.,  1914,  iii,  126. 


124 


THE    THYROID    GLAND 


Fig.  42. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  supra- 
clavicular  goiter  and  enlarged  aorta  with  transverse  heart. 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF    GOITER       125 


Fig.    43. — Differential    diagnosis    of    intra thoracic    goiter.      Radiograph    of 
elongated  aorta  with  transverse  heart. 


126 


THE    THYROID    GLAND 


Dorsal  vertebral  tuberculosis  with  an  abscess  may  give 
a  confusing  shadow.  Uncertainty  may  easily  be  overcome 
by  a  study  of  the  spine  by  means  of  anteroposterior  and 
oblique  or  lateral  radiographs,  which  will  show  distinctly 


Fig.    44. — Differential    diagnosis    of    intrathoracic    goiter.      Radiograph    of 
enlarged  thymus  gland. 


the  destruction  of  the  vertebrae,   with  the  accompanying 
kyphosis. 

Hodgkin's  disease  is  usually  manifested  in  the  medi- 
astinum by  multiple  glandular  enlargements.  The  enlarged 
glands  show  an  irregular  or  indistinct  outline,  which  should 
not  be  confused  with  intrathoracic  goiter.  It  is  often 


ROLE    OF    RADIOLOGIST    IN    DIAGNOSIS    OF    GOITER       127 

impossible  to  differentiate  this  condition  from  lympho- 
sarcoma  or  carcinoma.  However,  the  presence  of  enlarged 
glands  in  other  parts  of  the  body,  with  the  blood-picture, 
easily  establishes  the  diagnosis  of  Hodgkin's  disease. 


Fig.  4o. — Differential  diagnosis  of  intrathoracic  goiter.     Radiograph  of  en- 
larged thymus  gland. 


In  doubtful  cases  a  resection  of  one  of  the  superficial 
glands  may  be  made,  a  microscopic  study  of  which  will 
definitely  determine  the  diagnosis. 

Lung  abscess  at  the  hilus  may  sometimes  simulate 
intrathoracic  goiter.  By  careful  radiographic  examination 


128 


THE    THYROID    GLAND 


we  may  discover  a  fluid  level  in  the  abscess  cavity  sur- 
rounded by  an  irregular  inflammatory  area.  This,  with  the 
clinical  history,  determines  the  pathologic  condition. 

Osseous  tumor  of  a  rib,  enchondroma  of  the  chest  wall, 
or  tumor  of  the  vertebral  spine  is  usually  well  defined,  and 
the  origin  of  each  is  easily  determined  from  stereoscopic 
radiographs  of  the  chest. 


Fig.    46. — Differential   diagnosis   of   intrathoracic    goiter.      Radiograph    of 

apical  pneumonia. 


Pneumonia,  primarily  in  the  apex  of  a  lung,  may  give  a 
dense  shadow  extending  to  the  mediastinum,  but  the  history 
of  the  case  and  the  clinical  symptoms  are  so  evident  that 
there  should  be  no  difficulty  in  the  diagnosis  (Fig.  46). 

A  malignant  growth  in  the  lung  may  be  sarcoma  or 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       129 


Fig.  47. — Differential  diagnosis  of  intrathoracic  goiter.  Radiograph  of 
right  pneumothorax  showing  trachea,  heart,  and  aorta  displaced  to  the  left 
and  old  fibrous  tuberculosis  of  the  left  lung. 


130 


THE    THYROID    GLAND 


carcinoma,    either    primary    or    metastatic    in    character 
(Fig.  48). 

A  primary  malignant  growth  of  the  lung  almost  always 
develops  from  the  hilus  and  extends  toward  the  periphery. 
However,  it  may  arise  in  the  parenchyma.  The  normal 


Fig.^S. — Differential  diagnosis  of  intrathoracic  goiter.     Radiograph  of  sar- 
coma of  right  lung. 

mediastinal  shadow  is  displaced  to  the  opposite  side  and  the 
condition  is  associated  with  pleural  effusion. 

Metastatic  carcinoma  shows  the  typical  multiple  areas 
with  fuzzy  outlines,  as  has  been  described  by  Moore  and 
Carman.1 

1  Moore,  A.  B.,  and  Carman,  R.  D.,  A.  J.  Roentgenol.,  1916,  vol.  iii,  126. 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       131 

There  is,  however,  another  type  of  malignancy  with 
which  we  are  more  concerned,  described  by  Holmes  and 
Ruggles.1  This  type  is  found  in  the  hilus  and  simulates 
many  inflammatory  conditions;  but  presents  a  more  defi- 
nite dense  localized  mass  and  tends  to  extend  upward  with 
an  accompanying  mediastinitis  (Fig.  49).  These  masses 


Fig.  49. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  medi- 
astinal  tumor  (lymphosarcoma). 

often  become  well  defined  and  of  greater  size  at  the  sterno- 
clavicular  junctions  and  may  simulate  goiter,  but  they  are 
not  so  regular  in  outline  and  the  lower  border  cannot  be 
made  out  as  in  the  rounded  tumor  of  goiter. 

1  Holmes,  George  W.,  and  Ruggles,  Howard  E.,  Roentgen  Interpretation, 
1919,  p.  145. 


132 


THE   THYROID    GLAND 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       133 

An  esophageal  diverticulum  may  be  discovered  by  fluoro- 
scopic  examination  or  by  radiographs  when  it  contains  food 
or  fluid.  If  a  diverticulum  be  suspected  the  patient  is  given 
a  barium  mixture  and  then  radiographed  in  the  antero- 
posterior  and  oblique  positions.  The  plates  will  show  a 


Fig.    51. — Differential   diagnosis   of   intrathoracic    goiter.      Radiograph   of 
esophageal  diverticulum. 


dilated  pouch  which  is  connected  to  the  esophagus  and 
has  a  smooth  rounded  lower  end  with  no  opening  leading 
therefrom. 

These  shadows  are  typical  in  appearance  and  offer  little 
difficulty  in  diagnosis  (Figs.  50-53). 


134 


THE   THYROID   GLAND 


Fig.    52. — Differential    diagnosis    of   intrathoracic    goiter.      Radiograph    of 
esophageal  diverticulum. 


ROLE    OF   RADIOLOGIST    IN   DIAGNOSIS   OF   GOITER       135 


136 


THE    THYROID    GLAND 


Carcinoma  of  the  esophagus  may  be  determined  by 
filling  the  esophagus  with  a  thick  barium  mixture,  which 
will  show  a  dilatation  above  with  a  narrowing  below  (Figs. 
54,  55). 


Fig.  54. — Differential  diagnosis  of  intrathoracic  goiter.    Radiograph  of  car- 
cinoma of  the  esophagus. 


The  dilatation  above  the  carcinoma  is  usually  not  so 
pronounced  as  in  cardiospasm,  and  the  lower  end  of  the 
barium  shadow  is  irregular,  tapering  to  a  narrow  channel, 
which  also  is  irregular  in  outline. 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS   OF   GOITER       137 


138 


THE   THYROID   GLAND 


Fig.    56. — Differential    diagnosis    of    intrathoracic    goiter.      Radiograph    of 
metastatic  carcinoma  of  the  mediastinal   glands. 


ROLE    OF   RADIOLOGIST   IN   DIAGNOSIS    OF   GOITER       139 
SUMMARY 

1.  A  careful  radiologic  examination  should  be  made  in 
all  cases  in  which  the  clinical  symptoms  and  the  history 
of  the  case  lead  one  to  suspect  intrathoracic  goiter  or  thy- 
mus  disease. 

2.  Radiographs  should  be  made  in  every  case  by  rapid 
exposure  to  eliminate  pulsating  movements  in  the  medi- 
astinum. 

3.  The  movement  of  the  goiter  shadow  with  deep  in- 
spiration and  expiration  and  during  deglutition  is  almost 
pathognomonic . 

4.  Careful  study  of  the  spine,  ribs,  and  chest  wall  for 
pathology  associated  therewith  should  be  a  routine  pro- 
cedure. 


THE  VALUE  OF  BASAL  METABOLISM  STUDIES  IN 
EXOPHTHALMIC  GOITER 

CHESTER  D.   CHRISTIE 


THE  study  of  metabolism  dates  back  to  the  early  part 
of  the  seventeenth  century,  when  experiments  on  the 
"insensible  perspiration"  were  recorded  by  Sanctorius.  Fol- 
lowing Sanctorius  there  were  numerous  contributions  to 
the  subject  of  metabolism  by  such  distinguished  investi- 
gators as  John  Mayow,  Lavoisier,  Laplace,  and  Liebig.  It 
remained,  however,  for  the  whole  subject  of  metabolism 
to  be  established  on  a  firm  scientific  basis  by  the  work  of 
Pettenkofer  and  Voit.  The  observations  of  these  two  men 
on  the  metabolism  of  animals  and  normal  men,  measured 
by  means  of  a  respiration  calorimeter,  represent  the  real 
beginning  of  our  present-day  conception  of  the  science  of 
nutrition. 

We  are  indebted  to  subsequent  workers,  prominent 
among  whom  have  been  Rubner,  Lusk,  and  Benedict,  for 
the  elaboration  of  the  subject  of  nutrition  to  its  present  state 
of  scientific  development  in  so  far  as  it  bears  on  the  vital 
physiology  of  normal  men  and  animals.  To  these  investi- 
gators the  credit  is  largely  due  for  the  construction  of  that 
branch  of  physiology  which  in  all  probability  is  most  inti- 
mately concerned  with  the  future  health  and  happiness  of 
the  race. 

It  is  surprising  that  with  such  an  enormous  accumula- 
tion of  scientific  data  regarding  the  normal  nutrition  of 
men,  much  of  which  has  been  secured  by  modern  workers, 
it  is  but  recently  that  observations  on  nutrition  under 

141 


142  THE    THYROID   GLAND 

abnormal  conditions  have  been  attempted.  With  the 
exception  of  certain  scattered  and  desultory  attempts  the 
field  of  pathologic  metabolism  has  been  left  essentially 
clear  for  modern  workers.  Boothby,  D.  Du  Bois,  and 
E.  F.  Du  Bois  were  the  pioneers  in  the  application  of  basal 
metabolism  studies  to  the  clinic.  Their  work  has  been  just 
as  fundamental  and  quite  as  far  reaching  in  the  develop- 
ment and  application  of  basal  metabolism  studies  to  the 
clinic  as  was  that  of  Pettenkofer  and  Voit  in  their  applica- 
tion of  basal  metabolism  observations  to  the  study  of  normal 
vital  processes. 

DEFINITION 

By  metabolism  is  meant  the  changes  which  are  con- 
stantly taking  place  in  the  cells  of  the  organism  whereby 
new  cells  are  constructed  and  old  cells  are  destroyed. 
Metabolism  is  expressed  in  terms  of  the  energy  liberated  by 
the  physicochemical  or  the  electro-physico-chemical  union 
which  takes  place  in  the  tissues  after  food  which  has  been 
taken  by  mouth  and  broken  down  into  the  end-products 
of  digestion  has  been  absorbed  and  has  met  in  the  blood 
with  the  oxygen  which  is  taken  in  by  the  lungs.  Metab- 
olism is  a  process  of  oxidation  and  reduction  within  the 
cells  of  the  body,  as  a  result  of  which  nourishment  is  sup- 
plied and  heat  generated.  The  term  covers  much  which  it 
would  seem  is  utterly  hidden  from  us,  as,  for  instance: 
how  each  cell  receives  its  proper  proportion  of  nourishment 
and  heat;  what  happens  to  liver  cells  to  make  them  act 
individually  and  collectively  as  they  do;  what  takes  place 
in  the  kidney  to  make  its  cells  react  to  external  stimuli  and 
to  one  another  in  a  fashion  different  from  that  in  which 
the  cells  of  the  liver  react;  and  how  these  individual  cells, 
with  totally  different  functions,  keep  just  the  right  amount 
of  water  and  salt,  and  maintain  their  acid-base  equilibrium, 


VALUE   OF   BASAL   METABOLISM   STUDIES   IN   GOITER      143 

and  at  the  same  time  not  only  carry  on  their  own  special 
functions,  but  contribute  their  part  to  the  neighboring  cells. 
In  a  rather  crude  sense  the  human  body  may  be  looked  upon 
as  a  great  test-tube  in  which  millions  of  different  kinds  of 
reactions  are  going  on  at  the  same  time,  each  reaction 
independent  in  a  sense,  but  all  of  them  interdependent; 
and  all  these  reactions  are  included  in  the  one  term — 
"metabolism." 

Metabolism,  then,  is  the  very  basis  of  life,  the  unseen 
and  unheard  force  which  runs  along  on  lines  determined 
within  the  species,  making  possible  birth,  growth,  and 
development  of  bodily  or  mental  characteristics.  It  is 
through  this  complex  operation  which  we  term  metabolism 
that  the  organism  is  supplied  with  energy  to  do  the  day's 
work.  By  means  of  metabolism  we  are  supplied  with  an 
increased  power  if  we  are  called  upon  to  perform  a  muscular 
feat;  and,  on  the  other  hand,  if  we  are  inclined  to  lie  down 
and  rest,  the  mechanism  of  metabolism  is  equally  willing 
to  reduce  its  activity  to  the  minimum  and  to  rest  with  us. 
Metabolism  is  to  the  individual  what  civilization  is  to  the 
interaction  of  individuals.  Metabolism  is  the  architect, 
the  merchant,  the  doctor,  and,  in  addition,  it  is  the  power 
plant  which  makes  transportation  possible,  the  repair 
department  which  reconstructs  worn  parts.  In  youth, 
when  the  organism  is  fresh  and  vital,  the  processes  of 
metabolism  produce  a  surplus  of  energy;  conversely,  when 
the  organism  has  nearly  run  its  course,  these  processes 
become  less  liberal  in  their  production.  Thus,  by  its  infi- 
nite adaptability,  metabolism  makes  possible  the  playful 
activity  of  youth  as  well  as  the  slow  and  faltering  move- 
ments of  old  age. 

Numerous  attempts,  some  of  them  successful,  have 
been  made  to  devise  a  simple  method  for  the  measurement 


144  THE   THYROID   GLAND 

of  the  basal  metabolism  by  indirect  calorimetry.  This 
method  for  the  estimation  of  metabolism  demands  some 
means  by  which  the  individual  may  be  connected  by  a 
mouthpiece  with  a  spirometer  containing  oxygen,  the  nose 
being  clamped  so  that  the  amount  of  oxygen  consumed  by 
the  individual  can  be  measured  for  a  given  length  of  tune. 
From  the  amount  of  oxygen  used  the  rate  of  elimination  can 
be  estimated.  From  tune  to  time  numerous  investigators 
have  used  methods  based  on  this  principle  for  the  collection 
of  clinical  data.  The  information  accumulated  has  been 
buried  here  and  there  in  the  literature.  It  is  disconnected, 
and  in  the  majority  of  cases  the  obvious  technical  objections 
and  the  lack  of  established  standards  make  it  necessary  to 
disregard  the  findings.  Many  of  these  earlier  observations 
have  been  reviewed  by  Du  Bois,1  but  few  have  proved  to 
be  of  value.* 

NORMAL  FACTORS  WHICH  AFFECT  THE  METABOLIC  RATE 

Age. — In  applying  the  data  to  the  determination  of 
normal  standards  account  has  to  be  taken  of  the  fact  that 
the  metabolic  rate  varies  widely  between  the  extremes  of  age, 
and  that  this  age  variation  is  different  in  the  two  sexes. 
Du  Bois3  has  worked  out  graphically  the  normal  basal 
metabolism  in  the  male  from  infancy  to  the  age  of  eighty- 
three  years.  In  the  female  the  average  normal  rate  for 
each  age  is  about  8  per  cent,  lower  than  in  the  male.  It  is 
lowest  in  the  newborn  babe  and  reaches  its  maximum  at 
about  the  fifth  year,  from  which  age  it  gradually  declines 
throughout  the  life  of  the  individual.  For  the  average 
adult  male  the  normal  metabolic  rate  is  considered  to  be 
39.7  calories  per  hour  per  square  meter  of  body  surface; 

*  The  earlier  types  of  apparatus  for  the  measurement  of  metabolism  by 
indirect  calorimetry  have  been  described  by  Carpenter.2 


VALUE    OF   BASAL  METABOLISM   STUDIES   IN   GOITER      145 

and  for  the  average  adult  female  36.9  calories  per  hour 
per  square  meter  of  body  surface. 

Digestion. — The  metabolic  rate  may  be  increased  15  per 
cent,  above  the  normal  when  active  digestion  is  taking 
place.  This  increase  is  most  marked  after  the  ingestion  of 
cold  food  or  a  diet  rich  in  protein,  fat,  or  alcohol. 

Exercise. — Any  movement  of  the  voluntary  muscula- 
ture of  the  body  causes  some  increase  in  metabolism.  There- 
fore if  the  exercise  be  violent  enough  the  metabolic  rate 
may  be  increased  to  the  limit  of  which  the  individual  is 
capable.  The  increase  of  metabolism  caused  by  the  uncom- 
mon use  of  the  musculature  in  a  boat-race  must  be  very 
great  indeed. 

Excitement. — If  an  individual  whose  metabolism  is 
being  measured  becomes  unduly  excited  or  apprehensive,  a 
mild  increase  will  be  noted.  Excitement  plays  an  important 
role  when  metabolism  estimates  are  being  made  for  the 
first  time.  It  is  because  of  this  factor  that  we  advocate  two 
determinations  on  successive  mornings  before  conclusions 
are  drawn. 

Menstruation. — Recently  Snell,  Ford,  and  Rowntree4 
have  made  a  preliminary  report  showing  that  in  some 
instances  during  the  menstrual  period  the  metabolic  rate 
in  girls  may  be  increased  to  15  per  cent,  above  normal.  I 
have  made  the  same  observation. 

The  assurance  of  true  basal  conditions  demands  the 
elimination  of  all  such  factors  as  those  just  mentioned.  If 
basal  conditions  are  assured,  then  one  may  safely  conclude 
that  in  any  case  in  which  a  variation  from  the  normal 
metabolism  rate  has  been  established  some  pathologic  con- 
dition is  present. 


10 


146  THE    THYROID   GLAND 

ABNORMAL  CONDITIONS  WHICH  CAUSE  AN  INCREASE  IN  BASAL 

METABOLISM 

Fevers. — It  has  long  been  recognized  that  fever  causes 
an  increase  in  basal  metabolism.  Coleman  and  Du  Bois,5  in 
their  extensive  studies  on  the  basal  metabolism  of  patients 
with  typhoid  fever,  found  that  during  the  course  of  the 
fever  the  average  basal  metabolic  rate  was  increased  about 
40  per  cent.,  and  that  it  might  rise  to  even  50  per  cent, 
above  the  normal.  It  is  not  known  whether  or  not  this 
increased  metabolism  is  wholly  dependent  upon  the  fever. 
Doubtless  the  increase  in  protein  destruction  which  always 
accompanies  a  fever  is  an  important  element  in  the  height- 
ened metabolism.  During  a  chill  the  metabolism  may  rise 
to  a  very  high  level  above  the  normal. 

Anemia  and  Leukemia. — Cases  of  severe  anemia  show 
an  increase  in  basal  metabolism.  The  increase  always 
bears  an  inverse  relation  to  the  hemoglobin.  Mild  cases  of 
secondary  anemia  and  chlorosis  have  not  been  shown  to 
have  a  definite  increase  in  the  basal  metabolism.  Cases  of 
leukemia  show  an  increase  which  has  been  demonstrated 
as  more  or  less  constant  throughout  long  periods  of  observa- 
tion. All  the  cases  of  leukemia  in  our  series  have  shown  a 
definite  increase  up  to  50  per  cent,  above  the  normal  basal 
metabolic  rate. 

Diabetes  Mellitus. — Patients  with  severe  diabetes  have 
shown  an  increase  in  the  basal  metabolic  rate  which  is 
especially  evident  during  the  period  of  hyperglycemia  and 
acidosis.  This  increase  is  but  slight,  usually  not  more 
than  15  per  cent,  above  the  normal,  and  disappears  with 
the  return  to  a  normal  sugar  level  in  the  blood  and  with 
the  disappearance  of  acidosis.  In  fact,  during  periods 
when  there  is  no  sugar  in  the  urine  the  metabolism  may 
fall  well  below  the  normal  limit. 


VALUE   OF   BASAL   METABOLISM   STUDIES   IN   GOITER      147 

Cardiac  Dyspnea  and  Asthma. — In  cases  of  well-marked 
cardiac  decompensation  the  basal  metabolism  may  be 
increased  to  50  per  cent,  above  the  normal.  It  is  always 
well  to  bear  this  fact  in  mind,  particularly  when  studies  are 
being  made  on  goiter  patients  in  whom  decompensation  is 
present  or  threatened.  It  is  possible  to  fall  into  this  error, 
and  more  drastic  treatment  might  be  employed  when 
digitalis  would  suffice. 

In  cases  of  asthma  there  is  likewise  an  increase  in  met- 
abolism, as  we  have  found  repeatedly  in  our  series.  We 
have  made  a  few  observations  on  these  patients  both  during 
an  attack  and  immediately  after  the  arrest  of  the  attack 
by  the  use  of  adrenalin  injections.  The  results  of  these 
observations  will  be  recorded  elsewhere.  In  the  case  of 
both  cardiac  dyspnea  and  asthma  it  is  my  impression  that 
the  increased  metabolism  is  due  simply  to  the  increased 
work  occasioned  by  the  difficult  breathing. 

Pituitary  Disorders. — An  increase  in  the  basal  metab- 
olism has  been  observed  in  cases  of  acromegalia.  We  have 
had  but  one  patient  with  this  syndrome,  and  in  that  instance 
the  metabolism  was  increased  to  almost  50  per  cent,  above 
the  normal.  Recently  Snell,  Ford,  and  Rowntree6  have 
observed  a  moderately  increased  metabolism  in  two  cases  of 
diabetes  insipidus  during  the  phase  of  extreme  polyuria. 
In  these  cases  the  metabolism  became  normal  when  the 
great  increase  in  water  transportation  had  been  lessened  by 
the  use  of  pituitrin  injection. 

BASAL  METABOLISM  IN  EXOPHTHALMIC  GOITER 

The  first  metabolic  studies  on  exophthalmic  goiter 
patients  were  made  by  Friedrich  Miiller7  in  1893.  Miiller 
found  that  his  patients  with  exophthalmic  goiter  not  only 
were  eating  more  food  than  they  required  to  meet  their 


148  THE    THYROID   GLAND 

caloric  needs,  but,  in  addition,  they  were  excreting  more 
nitrogen  in  their  urine  than  they  were  taking  hi  their  food. 
This  meant  that  these  patients  were  not  utilizing  all  the 
increased  protein  of  their  own  bodies  in  an  effort  to  supply 
the  unnatural  demand.  In  other  words,  these  patients  were 
not  in  a  state  of  nitrogenous  equilibrium  and,  therefore, 
were  actually  in  a  state  of  starvation  even  though  they 
were  eating  and  utilizing  far  more  food  than  a  normal 
person  of  the  same  weight  and  height.  This  metabolism 
observation  by  Miiller  offered  the  first  explanation  of  the 
two  most  evident  and  paradoxic  manifestations  of  patients 
afflicted  with  exophthalmic  goiter,  i.  e.,  the  enormous  food 
consumption  and  the  marked  weight  loss. 

A  short  tune  after  the  observations  of  Miiller,  Magnus- 
Levy8  was  able  to  demonstrate  with  a  respiration  calor- 
imeter that  the  metabolism  of  patients  with  exophthalmic 
goiter  was  increased,  and  that  the  basal  metabolism  .of 
patients  with  myxedema  was  decreased.  Magnus-Levy 
was  the  first  investigator  to  use  basal  metabolism  studies  to 
control  the  treatment  of  his  patients. 

After  these  basic  observations  were  made  by  Miiller 
and  Magnus-Levy,  practically  no  attention  was  paid  to  the 
question  of  basal  metabolism  in  exophthalmic  goiter  until 
Du  Bois9  undertook  a  similar  study,  but  one  more  elaborate 
and  better  controlled  than  those  previously  made.  The 
findings  of  Du  Bois,  like  those  of  the  earlier  observers, 
emphasized  the  fact  that  the  most  characteristic  manifesta- 
tion of  exophthalmic  goiter  is  an  increase  in  the  basal 
metabolism  to  a  higher  degree  than  is  ever  reached  in  other 
conditions;  and  that,  moreover,  the  increased  metabolism 
is  the  most  constant  manifestation  of  the  disease.  The 
observations  and  conclusions  of  Du  Bois  have  been  confirmed 
by  Means  and  Aub,10  Boothby  and  Sandiford,11  McCaskey,12 
and  Christie.13 


VALUE    OF   BASAL   METABOLISM   STUDIES   IX   GOITER      149 

During  the  last  few  years  we  have  made  in  our  labora- 
tory a  total  of  826  basal  metabolism  measurements  on  472 
patients.  Among  these  patients  202,  or  just  slightly  less 
than  43  per  cent.,  showed  an  increase  in  metabolism  to 
more  than  15  per  cent,  above  the  normal;  and  we  believe 
that  in  each  instance  this  increase  was  due  to  an  exophthalmic 
goiter.  The  degree  of  the  increase  in  the  basal  metabolic 
rate  in  the  202  patients  may  be  summarized  as  follows: 

Number  showing  an  increase  of  from  15  to  55  per  cent. 

above  the  normal  metabolic  rate 121 

Number  showing  an  increase  of  from  55  to  85  per  cent. 

above  the  normal  metabolic  rate 60 

Number  showing  an  increase  of  more  than  85  per  cent. 

above  the  normal  metabolic  rate. . .  21 


202 


The  highest  basal  metabolic  rate  we  have  observed  in 
any  of  our  patients  was  170  per  cent,  above  the  normal. 
Four  other  determinations  were  made  on  this  patient,  and 
in  none  of  them  did  we  find  the  rate  lower  than  110  per  cent, 
above  normal. 

Some  patients  who  for  a  long  period  of  tune  have  had 
comparatively  mild  exophthalmic  symptoms,  with  very 
marked  cardiac  and  eye  signs,  may  show  a  very  slightly 
increased  metabolism — from  15  to  25  per  cent,  above  the 
normal.  In  this  group,  however,  metabolism  measurements 
are  not  a  very  accurate  index  to  the  degree  of  disability. 
This  may  be  due  to  the  fact  that  the  metabolic  rate  had 
previously  been  higher,  and  that  much  of  the  disability 
manifested  by  the  patients  at  the  tune  the  measurements 
were  made  was  no  longer  entirely  due  to  the  active  exoph- 
thalmic goiter,  but  rather  to  the  devastating  effects  of  the 
chronic  disease  upon  the  patient's  entire  system.  With 
most  cases,  however,  the  degree  of  the  increase  in  the 


150  THE   THYROID   GLAND 

metabolic  rate  does  give  a  fairly  accurate  index  of  the 
severity  of  the  disease. 

The  Value  of  Basal  Metabolism  Measurements  in  the 
Diagnosis  of  Exophthalmic  Goiter. — I  feel  that  the  greatest 
service  of  basal  metabolism  measurements  to  the  clinic  is 
the  aid  which  they  furnish  for  the  diagnosis  of  disease 
referable  to  the  thyroid  gland.  When  intelligently  inter- 
preted the  results  are  of  very  distinct  value,  and  supply  the 
clinic  with  an  additional  method  of  precision  which  is  quite 
as  useful  in  its  field  as  any  method  which  we  now  possess. 

Obviously  an  established  case  of  exophthalmic  goiter 
offers  very  little  difficulty  from  a  diagnostic  point  of  view. 
It  is  in  the  borderline  cases  that  we  have  found  metabolism 
measurements  of  the  greatest  service.  In  cases  in  which 
the  classical  symptoms  of  the  disease  are  present  but  the 
classical  signs  are  not  sufficiently  obvious  to  warrant  a 
definite  diagnosis,  repeated  careful  basal  metabolism  meas- 
urements are  of  inestimable  value  in  establishing  an  accurate 
diagnosis. 

Often  patients  are  encountered  who  do  not  have  the 
classical  signs  of  the  disease.  The  eye  signs  are  very  fre- 
quently absent  and  are  often  equivocal.  Enlargement  of 
the  thyroid  is  not  always  present,  but  is  far  more  constant 
than  the  eye  signs.  The  uniformly  enlarged,  hyperplastic 
and  vascular  gland,  with  palpable  thrills  and  audible 
murmurs,  is  a  very  constant  factor  in  the  disease.  Certain 
patients  with  thyroid  disease  may  not  have  any  demon- 
strable pathology  in  relation  to  the  thyroid,  but  they  are  in 
the  great  minority.  Other  patients  may  have  the  classical 
symptoms  of  the  disease  and  an  elevation  in  the  metabolic 
rate  with  only  an  innocent-feeling  adenoma  in  the  thyroid. 
The  one  most  constant  sign  of  exophthalmic  goiter  which 
we  have  found  is  the  uniform  enlargement  of  the  heart. 


VALUE    OF   BASAL   METABOLISM   STUDIES   IN   GOITER      151 

Of  course,  this  is  purely  a  compensating  factor  for  the  great 
increase  in  the  amount  of  blood  which  the  heart  is  called 
upon  to  transport  because  of  the  increased  metabolism.  If 
the  metabolism  is  greatly  increased,  it  is  obvious  that  the 
heart  will  be  much  larger  than  if  the  metabolism  is  only 
slightly  increased.  Therefore,  if  the  metabolism  be  only 
slightly  increased,  it  follows  that  the  relatively  slight 
increase  in  the  size  of  the  heart  will  be  harder  to  discover 
by  physical  examination.  From  my  own  experience  I  should 
consider  the  relative  value  of  the  various  signs  of  exophthal- 
mic goiter  in  the  following  order:  1.  Positive  anamnesis. 
2.  Uniform  dilatation  of  the  heart  with  rapid  rate,  provided 
other  factors  which  might  cause  these  heart  signs  have 
been  eliminated.  3.  Increased  basal  metabolism  established 
by  careful  and  repeated  measurements.  4.  Presence  of 
signs  directly  referable  to  the  thyroid  gland.  5.  Presence 
of  characteristic  eye  signs.  6.  Tremor,  sweating  hands,  and 
pigmented  skin. 

It  seems  certain  that  an  increase  in  basal  metabolism 
represents  the  fundamental  and  basic  symptom  of  exoph- 
thalmic goiter,  just  as  a  hyperglycemia  represents  the  basic 
symptom  of  diabetes  mellitus.  There  is  no  other  condition 
in  which  such  an  increase  in  metabolism  persists  seven 
days  out  of  the  week  and  thirty  days  out  of  the  month,  as 
is  the  case  in  exophthalmic  goiter.  An  increase  in  metab- 
olism may  be  produced  by  exercise;  but  the  exercise  would 
soon  be  discontinued  if  the  increased  metabolism  equaled 
or  approached  the  increase  found  in  some  patients  with 
exophthalmic  goiter.  Moreover,  exercise  causes  an  active 
increase  in  metabolism,  while,  in  the  case  of  exophthalmic 
goiter,  the  increase  in  metabolism  is  passive.  It  seems  prob- 
able that,  if  we  could  activate  the  metabolism  of  a  normal 
individual  to  the  same  degree  that  is  found  in  exophthalmic 


152  THE   THYROID   GLAND 

goiter,  and  could  continue  that  activation,  persistently, 
for  a  long  period,  all  the  classical  signs  and  symptoms  of 
the  disease  would  be  produced.  All  of  the  signs  and  symp- 
toms are  accentuated  in  proportion  to  the  increase  in  metab- 
olism, and  subside  as  the  metabolism  again  approaches  the 
normal.  This  is  particularly  true  with  regard  to  the  size  of 
the  heart. 

I  have  seen  active  exophthalmic  goiter  mistaken  for 
aortitis  in  two  or  three  cases.  In  each  of  these  instances 
basal  metabolism  estimates  were  of  distinct  service.  After 
my  attention  was  called  to .  these  mistaken  diagnoses  I 
began  observing  more  closely  the  aortas  in  patients  with 
exophthalmic  goiter.  I  observed  that  there  was  an  increase 
in  the  transverse  percussion  dulness  over  the  root  of  the 
aorta  in  many  of  these  patients;  and  that,  in  addition,  there 
was  a  palpable  systolic  impulse  and  diastolic  impact  over 
the  aortic  area.  On  several  occasions  I  have  been  able  to 
demonstrate  a  "tracheal  tug."  The  size  and  the  position 
of  the  heart  simply  added  to  the  confusion.  If  the  increase 
in  the  size  of  the  heart  is  due  to  dilatation,  caused  by  the 
greater  demand  for  the  increased  transportation  of  blood 
resulting  from  the  heightened  metabolism — and  this  seems 
to  be  the  obvious  explanation — then  it  would  appear  that  a 
dilatation  of  the  aorta  must  follow  as  a  matter  of  course. 
On  this  theory,  and  bearing  in  mind  the  results  of  many 
examinations  of  the  aorta  in  patients  with  exophthalmic 
goiter,  I  routinely  have  6-foot  rr-ray  plates  made  of  their 
hearts  and  aortas.  These  have  given  us  splendid  confirma- 
tion of  the  fact  that  in  many  cases  of  exophthalmic  goiter 
there  is  present  a  very  definite  widening  of  the  root  of  the 
aorta.  This  dilatation  of  the  aorta  recedes  as  the  metabolism 
is  reduced.  It  is  probable  that  it  is  not  confined  to  the  root 
of  the  aorta,  but  that  the  vessels  of  the  whole  vascular 


VALUE   OF   BASAL  METABOLISM   STUDIES   IN   GOITER      153 

system  of  the  patient  with  active  exophthalmic  goiter  are 
increased  in  their  cross  diameter. 

Value  of  Basal  Metabolism  Measurements  in  the  Con- 
trol of  Treatment. — Basal  metabolism  estimates  during 
the  course  of  the  treatment  of  patients  with  exophthalmic 
goiter  provide  a  very  accurate  index  to  the  progress  of  the 
disease.  They  supply,  as  it  were,  a  yard  stick  wherewith 
to  measure  the  intensity  of  the  disease  at  any  given  time. 
The  history  and  the  physical  examination  may  both  give 
rise  to  misleading  information  regarding  the  clinical  condi- 
tion of  the  patient.  From  the  history,  in  particular,  one 
is  apt  to  obtain  misleading  information  regarding  the 
clinical  condition  of  the  patient,  since  much  depends  on  his 
mental  attitude.  If  the  patient  be  inclined  to  optimism 
it  tends  to  mitigate  personal  feelings;  or,  conversely,  if  the 
patient  be  pessimistically  inclined,  his  personal  feelings 
may  be  exaggerated.  In  either  case  the  personal  history 
of  the  patient  with  exophthalmic  goiter  may  be  wrongly 
interpreted.  Basal  metabolism  measurements  will  obviate 
some  of  this  difficulty.  As  was  pointed  out  earlier  in  this 
paper,  the  physical  examination  of  the  patient,  although 
invaluable,  will  not  detect  slight  grades  of  change  in  the 
patient's  condition  with  the  same  precision  as  do  basal 
metabolism  measurements. 

The  treatment  of  exophthalmic  goiter  is  finally  deter- 
mined by  the  changes  in  the  basic  symptom  of  the  disease 
— the  variations  in  metabolism — just  as  the  treatment  of 
diabetes  mellitus  is  determined  by  changes  in  the  basic 
symptom  of  that  disease — the  variations  in  hyperglycemia. 
Therefore  any  rational  treatment  of  exophthalmic  goiter 
must  depend  upon  agents  which  are  known  to  reduce  the 
metabolism. 

The    Treatment    of   Exophthalmic    Goiter. — Numerous 


154  THE   THYROID    GLAND 

agents  have  been  employed  from  time  to  time  in  the  treat- 
ment of  exophthalmic  goiter.  It  seems  clear  that  if  any 
agent  is  to  be  successful  it  must  be  efficacious  in  reducing 
the  heightened  metabolism  which  is  known  to  exist  in  the 
disease.  There  are  several  procedures  which  are  known 
to  accomplish  this  purpose,  the  most  important  probably 
being  rest  in  bed.  This  rest  should  include  not  only  physical 
but  mental  rest,  as  exercise  and  mental  excitement  are  both 
factors  which  increase  the  metabolic  rate. 

The  question  of  food  is  also  an  important  factor.  If 
the  metabolism  of  a  patient  is  increased  100  per  cent, 
above  normal,  it  is  obvious  that  the  patient  needs  to  eat 
just  twice  as  much  food  if  the  body  weight  is  to  be  main- 
tained. It  has  long  been  known  that  certain  food-stuffs 
activate  metabolism  out  of  all  proportion  to  others.  As 
was  mentioned  earlier  in  this  article,  those  foods  are  pro- 
tein, fat,  and  alcohol.  It  is  apparent  that  these  food-stuffs 
should  be  avoided  in  the  treatment  of  exophthalmic  goiter, 
and  the  patients  should  be  maintained  as  nearly  as  possible 
on  the  one  food  which  is  known  not  to  activate  metabolism, 
namely,  carbohydrate.  The  appetite  of  these  patients 
should  be  encouraged  by  every  means  possible  so  that  they 
will  avoid  great  loss  in  weight.  It  seems  rational  to  employ 
the  duodenal  tube  for  forced  feeding  if  the  amount  of  food 
which  they  are  able  to  eat  is  not  sufficient  to  supply  their 
caloric  needs. 

It  is  our  custom  on  the  medical  service  of  this  hospital 
to  treat  exophthalmic  goiter  patients  with  adequate  rest 
and  diet,  as  was  outlined  above,  and,  in  addition,  we  employ 
the  x-ray.  Patients  are  given  maximum  exposure  to  the 
x-rays  over  the  thyroid  gland  about  every  three  weeks. 
Any  other  treatment  is  used  merely  symptomatically. 

In  Table  I  is  listed  a  group  of  patients  upon  whom  the 


VALUE    OF    BASAL   METABOLISM    STUDIES    IN    GOITER       155 


foregoing  procedures  have  been  employed.  In  selecting 
this  particular  group  from  our  series  I  have  been  guided 
by  the  fact  that  they  have  been  observed  for  the  longest 
period.  I  do  not  know  how  closely  they  have  adhered  to 
the  rest  regime,  for  most  of  them  have  been  here  under 
continuous  observation  for  only  short  periods.  The  number 
and  frequency  of  axray  treatments  have  also  been  vari- 
able, three  treatments  being  the  least  that  any  patient 
had  had,  and  seven  the  maximum. 

TABLE  I 

PATIENTS  WITH  EXOPHTHALMIC  GOITER  TREATED  BY  REST  AND  X-RAY 
ALONE  FOR  PERIODS  RANGING  FROM  THREE  MONTHS  TO  ONE  AND  A  HALF 
YEARS. 


On  admission. 

One  month  after 
treatment. 

Three  to  six  months 
afterward. 

Case  No. 

B.  M.  R., 

Pulse- 

B.  M.  R., 

Pulse- 

B.  M.  R., 

Pulse-rate. 

per  cent. 

rate. 

per  cent. 

rate. 

per  cent. 

79,867 

29 

110 

38 

90 

8 

90 

74,357 

33 

150 

48 

110 

42 

130  (patient  operated) 

72,768 

42 

110 

24 

110 

55 

120  (patient  operated) 

80,623 

54 

120 

9 

95 

23 

95 

76,872 

78 

110 

66 

95 

27 

80 

71,956 

77 

130 

52 

110 

77,700 

61 

105 

15 

180 

83,335 

59 

110 

48 

100 

(Doing  own 

work)  (patient  operated) 

75,552 

65 

110 

42 

92 

81,680 

25 

90 

13 

90 

26 

90 

77,439 

61 

105 

11 

75 

22 

75 

76,731 

48 

130 

25 

115 

50 

110  (patient  operated) 

81,18.5 

34 

110 

40 

85 

44 

40  (patient  operated) 

76,967 

18 

90 

12 

80 

4 

75 

In  all  of  these  patients  who  were  treated  by  x-ray  and 
rest  alone  there  were  times  when  the  metabolism  reached 
lower  figures,  and  in  many  there  were  higher  values  recorded. 
In  most  of  the  cases  in  which  there  were  pretty  violent 
recurrences  it  was  due  to  some  acute  infection  like  influenza 
or  tonsillitis. 

Through  the  kindness  of  Dr.  Crile  and  his  staff  I  have 
been  allowed  to  make  many  observations  on  their  exoph- 
thalmic patients,  both  before  there  was  any  surgical  inter- 
vention and  in  many  phases  of  the  postoperative  care. 


156 


THE   THYROID   GLAND 


In  Table  II  I  have  tabulated  a  group  of  patients  who  have 
been  treated  by  the  surgical  procedures  which  are  employed 
in  this  hospital.  In  choosing  this  particular  group  from 
the  large  series  upon  which  I  have  made  observations  I 
have  again  been  guided  by  the  fact  that  they  are  all  patients 
who  were  treated  more  than  a  year  and  a  half  ago,  and  I 
am  more  or  less  familiar  with  their  subsequent  course. 
Where  there  were  several  metabolism  measurements  made 
near  the  same  time  I  have  endeavored  to  strike  a  rough 
average.  The  pulse-rates  which  are  recorded  also  repre- 
sent the  approximate  mean  at  the  time  the  basal  metabolism 
measurements  were  made. 

This  table  represents  the  effect  of  surgical  treatment 
alone  on  the  metabolism  and  pulse-rate: 

TABLE  II 


Before. 

Approximately  two 
months  after  ligation 

Two  weeks  to  two  months 
after  operation. 

Case 

No. 

B.  M.  R., 

Pulse. 

B.  M.  R., 

Pulse. 

B.  M.  R., 

Pulse. 

per  cent. 

per  cent. 

per  cent. 

76,731 

50 

110 

15 

85 

16 

85  (2  weeks  after) 

81,185 

44 

112 

38 

105 

26 

96  (3  weeks  after) 

72,768 

24 

108 

35 

110 

10 

70  (2  weeks  after) 

76,477 

76 

110 

65 

120 

35 

92  (3  weeks  after) 

76,875 

93 

110 

65 

100 

18 

75  (2  weeks  after) 

73,579 

44 

120 

58 

120 

36 

90  (16  days  after) 

74,732 

120 

104 

135 

30 

96  (2  months  after) 

82,409 

95 

90 

24 

85  (1  year  after) 

83,335 

44 

110 

33 

100 

115  (3  weeks  after) 

74,357 

67 

150 

37 

92  (1  year  after) 

73,758 

44 

85 

12 

70  (1  month  after) 

I  should  not  wish  to  leave  the  impression  that  a  mere 
tabulation  of  the  metabolic  rate  and  the  pulse-rate  in  exoph- 
thalmic goiter,  as  shown  in  Tables  I  and  II,  represents  hi 
its  entirety  the  condition  of  the  patients.  As  has  been 
constantly  emphasized  in  this  article,  there  are  many  other 
clinical  factors  to  be  taken  into  consideration  in  determining 
the  result  of  treatment.  For,  after  all,  it  must  be  remem- 
bered that  basal  metabolism  measurements,  while  important 


VALUE    OF   BASAL   METABOLISM    STUDIES   IN   GOITER      157 

in  controlling  the  treatment  of  the  condition,  should  not 
supersede  careful  clinical  observation. 

The  tabulations  serve  to  emphasize  the  fact  that  rest 
and  exposure  to  the  x-ray,  ligation,  and  thyroidectomy 
are  all  very  potent  factors  in  reducing  heightened  metabo- 
lism, the  basic  symptom  of  exophthalmic  goiter,  and  there- 
fore favorably  affect  the  course  of  the  disease. 

It  will  be  found  that  the  pulse-rate  represents  a  fairly 
accurate  index  to  the  metabolic  rate.  In  exophthalmic 
goiter,  as  well  as  in  other  conditions  in  which  there  is  a 
known  increase  in  the  metabolic  rate,  the  increase  in  pulse- 
rate  represents  a  fairly  accurate  index  in  lieu  of  actual 
metabolism  measurements. 

CONDITIONS    WHICH   GIVE    RISE   TO   A    DECREASE   IN   BASAL 

METABOLISM 

The  conditions  which  cause  a  decrease  hi  the  basal 
metabolic  rate  are  myxedema,  cretinism,  and  general 
chronic  asthenic  conditions. 

Myxedema. — Most  of  the  adult  cases  of  myxedema 
which  we  have  encountered  have  followed  thyroidectomy. 
We  have,  however,  encountered  myxedema  in  patients  on 
whom  thyroidectomy  has  not  been  performed.  In  our 
series  we  have  considered  ten  cases  as  instances  of  the  adult 
type  of  myxedema.  Among  these  the  lowest  metabolic 
rate  was  39  per  cent,  below  normal. 

Cretinism. — We  have  encountered  but  one  case  of  what 
we  believed  to  be  a  juvenile  type  of  cretinism.  In  this  in- 
stance the  basal  metabolic  rate  dropped  as  low  as  20  per 
cent,  below  the  normal  level.  This  patient  was  markedly 
improved  by  the  oral  administration  of  thyroid  extract. 

Chronic  Asthenic  Conditions. — A  low  metabolic  rate 
is  frequently  encountered  in  elderly  individuals,  particu- 


158  THE   THYROID   GLAND 

larly  in  women  who  have  a  very  generalized  arteriosclerosis. 
A  low  metabolic  rate  may  occur  in  senile  diabetics  who 
are  sugar  free;  in  cases  of  chronic  tuberculosis  in  which 
there  is  no  fever,  and  in  old  people  with  chronic  bronchitis 
and  emphysema  without  "air  hunger.''  It  is  unusual  to 
find  the  metabolic  rate  more  than  15  per  cent,  below  the 
normal  in  this  class  of  patient.  The  metabolic  rate  is  not 
elevated  in  these  patients  by  the  administration  of  thyroid 
extract  nor  is  the  course  of  the  condition  favorably  affected. 

I  desire  to  express  my  thanks  to  Mr.  E.  J.  Warnick,  upon  whom  the  task 
of  much  of  the  routine  technical  work  involved  in  these  studies  has  fallen. 
His  careful  technic  and  kindness  to  the  patients  have  contributed  much  to  the 
value  of  our  efforts.  I  also  wish  to  express  thanks  to  our  chemical  assistant, 
Miss  Ruth  A.  Trump,  for  her  everwilling  assistance. 

BIBLIOGRAPHY 

1.  Du  Bois,  E.  F. :  Oxford  Medicine,  1920,  i,  379. 

2.  Carpenter,  R.  M.:  Pub.  216,  Carnegie  Institution  of  Washington'  1915. 

3.  Du  Bois,  D.  and  E.  F.:  Arch.  Int.  Med.,  1915,  xv,  868. 

4.  Snell,  A.  M.,  Ford,  Frances,  and  Rowntree,  L.  G.:  J.  A.  M.  A.,  1920,  Ixxv, 

515. 

5.  Coleman,  Warren,  and  Du  Bois,  E.  F.:  Arch.  Int.  Med.,  1915.  xv,  887. 

6.  Snell,  Ford,  and  Rowntree:  Loc.  cit. 

7.  Mtiller,  Friedrich:  Deutsch.  Arch.  f.  klin.  Med.,  1893,  li,  335. 

8.  Magnus-Levy:  Berl.  klin.  Wchnschr.,  1895,  xxxii,  650,  and  Ztschr.  f.  klin. 

Med.,  1897,  xxxiii,  269. 

9.  Du  Bois,  E.  F.:  Arch.  Int.  Med.,  1916,  xvii,  915. 

10.  Means,  J.  H.,  and  Aub,  J.  C.:  J.  A.  M.  A.,  1917,  Ixix,  33. 

11.  Sandiford,  Irene:  Endocrinology,  1920,  iv,  71. 

12.  McCaskey,  G.  W.:  J.  A.  M.  A.,  1919,  Ixxiii,  243. 

13.  Christie,  C.  D.:  Ohio  State  M.  J.,  1919,  xv,  708. 


THE  PREVENTION  OF  SIMPLE  GOITER  IN  MAN* 

O.  P.  KIMBALL 


To  understand  why  anyone  should  undertake  a  goiter 
survey  of  a  whole  community  for  the  purpose  of  establish- 
ing a  principle  of  prevention  by  a  simple  and  practical 
method  it  is  necessary  to  study  the  literature  of  goiter  with 
this  idea  in  view.  For  the  literature,  while  rich  in  state- 
ments regarding  the  distribution  of  goiter,  the  pathology 
of  the  thyroid  gland,  methods  of  medical  and  surgical 
treatment,  hereditary  tendencies  and  etiology,  has  little 
indeed  to  offer  regarding  the  prevention  of  goiter. 

A  survey  for  merely  determining  the  incidence  of  goiter 
in  the  different  localities  and  cities  of  this  portion  of  the 
Great  Lakes  basin  would  have  been  unnecessary.  There 
is  an  abundance  of  scientific  data  giving  in  general  the 
geographic  distribution  of  endemic  goiter  throughout  the 
world.  Surveys  of  various  communities  in  Europe  have 
been  made,  and  the  scientific  data  of  the  last  century  has 
so  emphasized  the  sociologic  and  economic  importance 
of  endemic  goiter,  cretinism,  and  deaf-mutism  that  national 
commissions  have  been  appointed  by  some  of  the  countries 
of  Europe  to  study  this  problem  for  the  purpose  of  finding 
some  method  of  relief. 

For  ten  years  preceding  the  beginning  of  our  work 
in  Akron,  Marine  and  Lenhart,  working  in  the  Depart- 
ment of  Experimental  Medicine  of  the  Western  Reserve 
University,  had  been  showing  the  ease  with  which  endemic 

*  Thesis  for  degree  of  Master  of  Arts  in  Medicine,  Western  Reserve 
University,  June,  1921. 

159 


160  THE   THYROID    GLAND 

goiter  could  be  prevented.  The  results  of  laboratory  experi- 
ments and  demonstration  in  animals,  however  convincing, 
must  be  applied  to  man  for  final  proof  of  their  prophylactic 
or  therapeutic  value.  The  prevention  of  goiter  in  man 
was  yet  to  be  proved.  Therefore,  with  Dr.  David  Marine, 
I  undertook  to  establish  in  man  the  applicability  of  the 
work  of  Marine  and  Lenhart  as  summed  up  in  their  state- 
ment that  "simple  goiter  is  the  easiest  of  all  known  diseases 
to  prevent." 

DEFINITION  AND  HISTORY  OF  ENDEMIC  GOITER 

The  term  "goiter"  means  hypertrophy  of  the  thyroid 
gland.  The  term  as  used  in  this  paper  refers  only  to  what 
is  known  as  simple  or  endemic  goiter,  and  does  not  include 
the  so-called  exophthalmic  goiter. 

The  incidence  of  simple  goiter  has  been  so  high  and 
so  continuous  for  generations,  in  certain  districts  of  the 
world,  where  all  kinds  of  domestic  animals  as  well  as 
humans  are  involved,  that  it  has  come  to  be  considered 
as  characteristic  of  or  endemic  in  those  districts. 

The  study  of  the  history  of  this  disease  is  like  studying 
the  history  of  the  human  race.  The  Arthorva  Veda,  an 
ancient  Hindu  collection  of  incantations  dating  from  2000 
B.  C.,  contains  extensive  forms  of  exorcisms  for  goiter. 
Caesar  mentions  the  frequent  occurrence  of  big  neck  as 
one  of  the  peculiar  characteristics  of  the  Gauls.  The  origin 
of  the  term  "cretin"  shows  the  familiarity  of  the  early 
Romans  with  this  disease.  They  originated  this  expression 
ojLcjontem.pt  by  calling  the  myxedematous  idiots  Christians. 
The  Swiss  physician,  Paracelsus  (1493-1541),  was  the 
first  to  emphasize  the  relationship  between  goiter  and 
cretinism,  and  the  earliest  positive  information  concern- 
ing the  latter  disease  dates  from  this  author.  In  1793 


THE    PREVENTION   OF   SIMPLE   GOITER   IN   MAN          161 

appeared  Fodere's  essay  on  Goiter  and  Cretinism  in  the 
Maurienne  and  Aosta  Valley;  and  in  1800  his  Treatise  on 
Goiter  and  Cretinism.  During  the  last  century  there  have 
been  numerous  publications  on  Endemic  Goiter  and  Cretin- 
ism, one  of  the  most  exhaustive  of  which  is  by  A.  Hirsch 
in  his  study  of  The  Historical  and  Geographical  Relations 
of  Goiter. 

-  About  the  middle  of  the  last  century  the  governments 
of  the  European  countries  began  to  see  the  economic  and 
sociologic  importance  of  this  problem.  In  1848  the  Sardinian 
Government  appointed  a  commission  to  study  the  cause 
of  endemic  goiter  and  find  some  method  of  relief.  In  1864 
the  French  Government  appointed  a  similar  commission, 
which  reported  in  1874  that  at  least  one-half  million  people 
in  France  were  suffering  from  goiter  and  that  there  were 
over  120,000  cretins  and  cretinoid  idiots.  This  commission 
seemed  to  establish  as  a  scientific  fact  the  popular  idea 
that  goiter  is  a  water-borne  disease.  In  1908  Switzerland 
created  a  goiter  commission,  and  since  then  Italy  has 
created  a  similar  commission  to  study  the  cause  and  pre- 
vention of  endemic  goiter. 

DISTRIBUTION 

The  extent  to  which  goiter  prevails  throughout  the 
world  is  seldom  appreciated.  Few  countries  are  free  from 
endemic  districts  and  we  find  the  so-called  sporadic  cases 
of  goiter  in  every  section  and  among  every  nationality  in 
the  world.  But  there  are  localities  where  the  incidence 
of  goiter  is  so  extremely  high  that  they  have  been  known 
for  years  as  endemic  goiter  districts.  The  best  known  of 
these  districts  is  in  southern  Europe,  or  more  specifically 
the  Alps  mountain  region,  comprising  southeastern  France, 

southern  Germany,  all  of  Switzerland,  northern  Italy,  and 
11 


162  THE    THYROID    GLAND 

southern  Austria.  In  Asia  practically  all  of  the  Himalaya 
district  is  an  endemic  goiter  belt,  with  a  very  high  incidence 
in  northern  India  and  parts  of  southern  and  western  China 
and  eastern  Mongolia.  In  South  America  goiter  is  endemic 
throughout  most  of  the  Andes  region,  with  probably  the 
highest  incidence  of  both  goiter  and  cretinism  on  the 
Peruvian  plateau  and  in  parts  of  western  Brazil.  In  North 
America  goiter  is  endemic  in  the  whole  of  the  Great  Lakes' 
basin,  in  the  basin  of  the  St.  Lawrence,  and  in  the  north- 
west Pacific  region. 

In  each  of  these  large  endemic  regions  there  are  localities 
in  which  the  incidence  of  goiter  is  much  higher  than  in  the 
surrounding  territory,  and  in  such  districts  all  of  the  domestic 
animals  are  affected.  In  some  of  these  smaller  districts 
the  incidence  of  goiter  has  been  determined  with  sufficient 
accuracy  to  be  mentioned  here.  For  example,  as  we  have 
stated  above,  in  1874  the  goiter  commission  of  France 
estimated  that  in  that  country  there  were  half  a  million 
goitrous  people  and  120,000  cretins  and  cretinoid  idiots; 
statistics  furnished  by  Kocher  show  that  80  to  90  per  cent, 
of  the  school  children  of  Berne  were  goitrous;  in  his  recent 
reports  Klinger  states  that  in  some  of  the  schools  of  Zurich, 
where  he  is  carrying  out  methods  of  goiter  prevention, 
100  per  cent,  of  the  children  are  goitrous.  In  southern 
Bavaria,  according  to  the  statistics  of  Schittenhelm  and 
Weichardt,  wrho  base  their  conclusions  on  examinations 
of  school  children,  the  incidence  of  goiter  is  as  high  as  from 
77  to  89  per  cent,  of  the  total  population.  In  Switzerland 
and  certain  provinces  of  Italy,  France,  and  Austria  the 
problem  of  endemic  goiter,  cretinism,  and  deaf-mutism 
has  been  recognized  as  of  sufficient  economic  importance 
to  demand  investigation  by  their  respective  governments. 

We  are  told  that  on  the  Gobi-desert  and  the  Plateau 


THE   PREVENTION    OF    SIMPLE    GOITER   IN   MAN  163 

of  Thibet  the  incidence  of  goiter  is  very  high,  and  that 
among  the  various  tribes  of  southeastern  Mongolia  one- 
third  of  the  population  is  goitrous. 

McCarrison  carried  out  some  of  his  researches  and 
made  several  surveys  in  Himalayan  India.  He  states 
that  in  some  of  the  villages  of  this  section  it  is  difficult 
to  find  a  man,  woman,  or  child  who  is  not  suffering  from  the 
deformity.  He  estimates  that  not  less  than  20  per  cent, 
of  the  total  population  of  Gilgit  in  northern  India  suffer 
from  goiter,  and  that  among  a  population  of  70,000  he 
found  200  cretins. 

The  frequency  of  goiter  in  North  America  has  been 
known  in  a  general  way  for  more  than  a  century.  In  1800 
Barton  wrote  an  excellent  monograph  on  the  occurrence 
of  goiter  among  the  American  Indians  living  along  the 
shores  of  Lakes  Ontario  and  Erie.  Other  goiter  centers 
among  the  Indians  of  the  Rocky  Mountain  States  have 
been  described  by  Munson.  Adami  pointed  out  the  fre- 
quency of  goiter  in  the  St.  Lawrence  Valley,  and  speaks 
of  French  Canadian  villages  in  this  district  in  which  there 
was  scarcely  a  family  without  one  or  more  goitrous  mem- 
bers. Osier  has  emphasized  the  frequency  of  goiter  in 
Ontario.  Marine  finds  the  disease  widely  disseminated 
all  along  the  Great  Lakes,  where  it  occurs  not  only  in  humans 
but  also  in  animals,  especially  dogs  and  sheep.  In  a  report 
to  the  Commission  of  Conservation  of  Canada  in  1918 
Shepherd  states  that  the  incidence  of  goiter  is  very  high  in 
British  Columbia  and  Alberta,  and  that  in  some  localities  of 
these  large  states  most  of  the  domestic  animals  are  affected. 

INCIDENCE  OF  GOITER  IN  THE  UNITED  STATES 

Efforts  to  determine  the  incidence  of  goiter  in  different 
sections  of  the  United  States  have  been  made,  but  no 


164  THE   THYROID   GLAND 

accurate  survey  of  a  whole  community  had  been  reported 
previous  to  our  work  in  Akron.  In  1913  Clark  examined 
13,836  school  children  in  eleven  counties  of  West  Virginia 
and  found  1234  cases  of  goiter — 9  per  cent,  of  the  number 
examined.  In  Virginia  the  same  worker  examined  6432 
school  children  and  found  817  cases  of  goiter,  or  12  per 
cent,  of  the  number  examined.  In  Huntington  50  per  cent, 
of  the  girl  students  were  found  to  be  affected.  In  the 
Virginia  survey  less  than  0.1  per  cent,  of  the  goiters  found 
were  among  boys. 

The  report  of  Hall  of  3339  students  at  the  University 
of  Washington  is  indicative  of  the  incidence  of  goiter  in 
the  Northwestern  States.  This  writer  found  enlarged 
thyroids  in  18  per  cent,  of  2086  men  whose  average  age  was 
twenty  years  and  five  months,  and  in  31  per  cent,  of  the 
1253  women  examined  whose  average  age  was  nineteen 
years  and  three  months. 

In  Chicago  Olson  examined  606  women  and  193  men, 
with  ages  ranging  from  eighteen  to  sixty  years.  Among 
the  women  18  per  cent,  had  well-developed  goiters  and  7 
per  cent,  of  the  men  were  affected. 

During  1917  and  1918,  when  so  many  of  our  young  men 
were  in  camp,  an  opportunity  was  offered  to  determine 
the  incidence  of  goiter  among  young  men  and  to  compare 
the  incidence  of  goiter  in  different  sections  of  the  country. 
Thus,  from  Camp  Lewis,  Washington,  Kerr  reported  the 
examination  of  21,182  recruits,  with  the  finding  of  1276 
large  or  well-formed  goiters.  The  percentage  of  unques- 
tionable goiters  compared  to  the  number  of  recruits  from 
each  state  was  as  follows: 

Per  cent.  Per  cent. 

Washington 11.0  Minnesota 5.1 

Oregon 8.6  Wyoming 3.7 

Idaho 7.3  South  Dakota 2.0 

North  Dakota 6.6  Nevada 1.1 

Utah...  5.5  Colorado...  .0.5 


THE   PREVENTION   OF   SIMPLE   GOITER   IN   MAN 


165 


Brendel  and  Helm,  studying  the  same  problem  at  Camp 
McDowell,  California,  conclude  that  goiter  is  endemic  in 

GOITER,  SIMPLE: 


*ATIO  PER   1000  MEN 


TOTAL,    CAMPS    AND   LOCAL    BOARDS 


GOITER,  EXOPHTHALMIC 


RATIO  PER  1000  MEN  TOTAL.  CAMPS   AND  LOCAL  BOARDS 

Fig.  57. — Comparative  incidence  of  goiter,  simple  and  exophthalmic,  in 
the  various  regions  of  the  United  States.  (Love,  Albert  G.,  and  Davenport, 
Charles  B.:  Defects  Found  in  Drafted  Men,  1920,  p.  86.  Reproduced  by 
permission  of  the  Surgeon-general.) 

Washington  and  Oregon.     Smith,   at  Jefferson  Barracks, 
Missouri,  reports  that  in  the  examination  of  65,507  men 


166  THE   THYROID    GLAND 

there  were  found  1074  cases  of  simple  goiter,  or  an  incidence 
of  1.63  per  cent,  of  the  total  number  examined.  These 
recruits  represented  fifteen  different  central  and  western 
states  (Fig.  57).  These  findings  only  emphasize  in  a  general 
way  the  fact  that  goiter  may  be  considered  as  distinctly 
endemic  in  certain  sections  of  the  United  States. 

THE  PHYSIOLOGY  OF  THE  THYROID 

In  order  to  appreciate  the  principle  of  goiter  prevention 
one  must  review  briefly  the  biochemistry  and  function  of 
the  thyroid  gland. 

Early  in  the  sixteenth  century  Paracelsus  emphasized 
the  relation  between  endemic  goiter  and  cretinism.  In 
1825  Parry's  descriptions  of  cases  of  goiter  or  enlargement 
of  the  thyroid  gland  in  connection  with  enlargement  of  the 
heart  with  palpitation  and  exophthalmos  were  published. 
In  1835  appeared  Graves'  description  of  the  clinical  complex 
of  exophthalmic  goiter,  with  enlargement  of  the  thyroid 
as  one  of  the  cardinal  symptoms.  Basedow's  description 
of  the  same  syndrome  appeared  in  1840.  But  none  of 
these  observers  interpreted  their  findings  in  terms  of  the 
function  of  the  thyroid.  The  first  important  observations 
of  the  functions  of  the  thyroid  were  published  in  1874 
by  Sir  William  Gull.  At  this  time  the  clinical  complex  of 
myxedema  (Gull's  disease)  was  described  in  detail,  and 
this  clinical  picture  was  interpreted  as  in  some  way  asso- 
ciated with  a  lack  of  function  of  the  thyroid. 

Gull's  observations  and  interpretation  of  the  etiology 
of  myxedema  were  confirmed  in  1880  and  1881  by  Kocher 
and  Reverdin,  who  had  observed  the  results  of  the  total 
removal  of  goitrous  thyroids.  Kocher  gave  to  the  clinical 
syndrome  resulting  from  complete  thyroidectomy  the  name 
of  cachexia  strumipriva;  Reverdin  called  it  operative 


THE    PREVENTION    OF    SIMPLE    GOITER    IN    MAN  167 

myxedema.  In  1877  Ord  designated  the  disease  as  myx- 
edema,  because  he  thought  he  had  recognized  a  mucoid 
change  in  the  subcutaneous  tissue.  Sir  Victor  Horsley 
verified  the  findings  of  these  observers  by  his  researches  on 
experimental  myxedema  in  monkeys.  As  a  result  of  these 
observations  Murray  and  McKenzie  in  1891  gave  glycer- 
inated  thyroid  extract  to  a  myxedematous  patient  and 
obtained  definite  therapeutic  results. 

The  early  Greeks  treated  goiter  by  the  internal  adminis- 
tration of  the  ash  of  burned  sea  sponges,  not  knowing 
that  the  substance  was  rich  in  iodids.  lodin  was  first 
knowingly  used  in  the  treatment  of  goiter  by  Coindet  in 
1820.  From  that  time  iodin  wras  used  very  extensively 
and  stood  alone  in  goiter  therapy  for  seventy-five  years 
before  the  discovery  by  Baumann  in  1895  that  iodin  was  a 
normal  constituent  of  the  thyroid  gland.  Our  knowledge 
of  the  chemistry  of  the  thyroid  progressed  rapidly  after 
Baumann's  discovery.  In  1901  Oswald  showed  that  the 
iodin  is  bound  with  the  globulin  and  is  contained  for  the 
most  part  in  the  colloid. 

In  1907  Marine  emphasized  the  fact  that  iodin  is  neces- 
sary for  the  normal  function  of  the  thyroid,  and  also  that  in 
active  hyperplasia  of  the  thyroid  the  iodin  store  is  reduced. 
The  later  experiments  of  Marine  and  Lenhart  have  estab- 
lished the  following  facts  relative  to  the  importance  of 
iodin  in  the  chemistry,  function,  and  histologic  anatomy 
of  the  thyroid: 

(1)  Iodin  is  a  constituent  of  the  normal  thyroid  of 
all  animals  with  the  ductless  thyroid.  As  shown  by  their 
experiments  on  the  rapidity  of  absorption  of  iodin  by  the 
thyroid,  and  its  elaboration  into  the  active  hormone,  and  by 
alkaline  hydrolysis  as  introduced  by  Kendall,  iodin  exists 
in  the  thyroid  in  an  active  and  inactive  form.  That  is,  the 


168  THE    THYROID    GLAND 

elaboration  of  the  hormone  goes  on  slowly  from  the  inactive 
iodin  collected  from  the  blood.  The  excess  of  physiologically 
active  iodin  is  for  the  most  part  stored  in  the  "colloid" 
or  globulin  of  the  alveoli,  and  it  is  believed  the  colloid 
serves  merely  as  the  vehicle  or  means  of  storing  the  excess 
of  this  remarkably  active  substance  in  a  harmless  manner. 
The  store  of  iodin  then  normally  consists  of  inactive  iodin 
for  the  most  part  in  the  cells,  and  of  active  iodin  for  the 
most  part  in  the  colloid  or  thyroglobulin. 

(2)  This  store  of  iodin  shows  wide  variations  in  any 
series  of  animals.     These  variations  reach  their  maximum 
in  the  so-called  goiter  districts  and  their  minimum  in  non- 
goitrous  districts. 

(3)  Further,  these  variations  in  iodin  store  have  been 
shown  to  have  an  intimate  relation  with  the  histology  of 
the  gland.     Thus,  in  all  species  of  animals  with  the  duct- 
less thyroid  the  iodin  store  is  decreased  in  the  hyperplasias. 
This  decrease  is  proportional  to  the  degree  of  hyperplasia. 
In  mammals — e.  g.,  dog,  sheep,  ox,  pig,  rabbit,  cat,  and 
man — it  has  been  shown  that  normal  thyroids  have  the 
highest  percentage  of  iodin,  averaging  0.2  per  cent.,  with 
extremes  of  0.1  and  0.5  per  cent. 

(4)  It  has  been  further  shown  that  as  soon  as  the  store 
of  iodin  falls  below  0.1  per  cent,  active  hypertrophic  and 
hyperplastic  changes  in  the  thyroid  begin.    In  other  words, 
no   functional   hyperplasia   and,   therefore,   no   goiter   can 
develop,  at  least  in  the  mammals  above  mentioned,  if  the 
iodin  store  in  their  thyroids  is  maintained  above  0.1  per 
cent. 

(5)  This  iodin  store  may  be  rapidly  and  markedly  in- 
creased by  the  administration  of  exceedingly  small  quan- 
tities of  iodin  in  any  known  form  and  through  a  great 
variety   of  means,   as   inhalation,   enteral   and  parenteral 


THE    PREVENTION    OF    SIMPLE    GOITER   IN   MAN          169 

administration,  cutaneous  application,  etc.,  and,  as  indi- 
cated above,  marked  histologic  changes  are  at  the  same 
time  brought  about  in  hyperplastic  glands,  viz.,  the  arrest 
of  the  hypertrophy  and  the  involution  or  return  of  the 
thyroid  cells  to  their  resting  form. 

The  active  iodin  compound  found  in  the  thyroid,  be- 
ginning with  its  discovery  by  Baumann  in  1896,  and  the 
successive  attempts  to  isolate  it,  has  been  known  as  iodo- 
thyrin,  iodo-thyroglobulin  (Baumann  and  Roos),  thyroidin 
(Oswald),  and  thyroxin  (Kendall).  In  1915  Kendall  suc- 
ceeded in  isolating  this  iodin-containing  hormone  in  crystal- 
line form  and  has  determined  its  structural  formula.  He 
believes  it  to  be  tri-iodo-indol-propionic  acid. 

In  1895  Magnus-Levy  indicated  that  the  thyroid  in 
some  way  controlled  the  rate  of  oxidation  in  the  tissues. 
He  showed  that  in  myxedema  the  rate  of  metabolism  was 
much  lowered  and  that  by  feeding  thyroid  the  rate  could 
be  raised.  Also  he  was  the  first  to  demonstrate  that  as 
regards  metabolism  exophthalmic  goiter  was  the  opposite 
to  myxedema.  This  work  has  been  confirmed  from  many 
sources  as  regards  experimental  and  spontaneous  myx- 
edema. And  as  regards  exophthalmic  goiter,  it  has  so 
developed  that  at  present  the  rate  of  metabolism  is  the 
best  available  basis  for  classification. 

In  a  recent  publication  on  "The  Physiology  of  the 
Thyroid,"  Marine  states  that  "The  thyroid  has  to  do  in 
some  important  way  with  internal  respiration  or  the  utiliza- 
tion of  oxygen  by  the  tissues.  Indeed,  this  is  the  only 
known  function  of  the  thyroid." 

THE  PREVENTION  OF  GOITER 

Before  1896  Halsted  had  shown  that  if  a  portion  of 
the  thyroid  is  removed  or  destroyed  the  remainder  under- 


170  THE    THYROID    GLAND 

goes  hyperplasia.  Marine  and  Lenhart  found  that  this 
compensating  hyperplasia  could  be  prevented  if  the  re- 
mainder of  the  thyroid  was  kept  saturated  with  iodin. 
This  was  true  in  dogs  as  long  as  at  least  one-sixth  of  the 
gland  was  left,  but  if  more  than  five-sixths  was  removed 
a  compensatory  hyperplasia  followed  even  though  iodin 
was  given.  This  important  observation  pointed  directly 
to  iodin  as  the  means  for  the  prevention  of  thyroid  hyper- 
plasia (goiter). 

One  of  the  first  practical  applications  of  the  principle 
of  prevention  of  goiter  and  myxedema  accidentally  fol- 
lowed the  discovery  of  salt  in  Michigan,  and  its  more  exten- 
sive use  (as  crude  salt)  in  the  sheep  industry  of  this  state 
at  a  time  when  the  industry  was  being  crippled  by  endemic 
goiter.  This  crude  salt  was  afterward  found  to  be  rich  in 
iodin.  The  first  definite  application  of  the  use  of  iodin 
in  the  prevention  of  goiter  on  a  large  scale  in  animals  was 
the  prevention  of  goiter  in  brook  trout.  This  disease  had 
been  the  cause  of  much  trouble  and  expense.  The  so-called 
thyroid  carcinoma  in  brook  trout  had  become  so  serious 
at  the  state  fish  hatchery  at  Shady  Grove,  Pennsylvania, 
that  the  question  of  abandoning  the  industry  was  being 
discussed.  An  investigation  of  the  causation  and  a  study 
of  methods  of  prevention  was  undertaken  by  Marine  and 
Lenhart  in  conjunction  with  the  Pennsylvania  State  Fish 
Commission  during  the  years  1909,  1910,  and  1911.  Their 
conclusions  as  to  the  etiologic  factors  producing  goiter 
and  the  practical  method  of  its  prevention  were  definite 
and  convincing.  The  important  factors  which  in  this 
instance  caused  endemic  goiter  were:  (1)  overfeeding 
with  an  artificial  food;  (2)  overcrowding.  These  investi- 
gators showed  that  goiter  could  be  prevented  in  young 
fish,  under  the  same  environmental  conditions  which  pro- 


THE    PREVENTION    OF    SIMPLE    GOITER    IN    MAN  171 

duced  goiter,  by  adding  a  very  small  amount  of  iodin  to 
the  food  or  water,  or  it  could  be  prevented  by  changing 
the  diet  and  remedying  the  overcrowding.  The  results 
of  this  practical  research  have  been  far  reaching. 

In  addition  to  the  experimental  work  above  mentioned 
the  treatment  of  goiter  with  iodin  at  the  Dispensary  at 
Lakeside  Hospital  had  been  followed  for  the  past  ten  years. 
Also  the  maternity  dispensary  of  Lakeside  Hospital  had 
not  only  been  using  iodin  in  the  treatment  of  goiter,  but 
had  been  using  it  as  a  prophylactic  measure  during  preg- 
nancy. To  most  of  the  men  in  touch  with  the  goiter  clinic 
at  Lakeside  or  the  School  of  Medicine  the  prevention  of 
goiter  was  no  longer  an  experiment,  but  an  accomplished 
fact. 

Therefore,  at  the  beginning  of  our  work  in  Akron  the 
possibility  of  goiter  prevention  had  been  clearly  demon- 
strated by  animal  experimentation,  but  only  a  very  limited 
application  of  methods  of  prevention  had  been  made  in 
man.  No  subject  in  preventive  medicine  had  a  sounder 
or  more  scientific  basis  for  its  practical  application  to  man 
on  a  large  scale  than  the  prevention  of  endemic  goiter. 
Yet  there  was  considerable  criticism  and  opposition  which 
had  to  be  overcome.  This  criticism  centered  about  the 
possible  untoward  effects  of  iodin,  especially  the  danger 
of  producing  exophthalmic  goiter. 

ETIOLOGY  OF  ENDEMIC  GOITER 

Before  any  one  can  fully  comprehend  the  fundamental 
principles  underlying  the  method  of  prevention  which 
we  have  used  he  must  have  some  conception  of  the  factors 
causing  the  disease.  There  have  been  many  theories  as 
to  the  cause  of  goiter,  most  of  which  are  only  of  historic 
value  and  will  not  be  taken  up  here.  At  present  there  are 


172  THE    THYROID   GLAND 

a  few  who  consider  goiter  as  a  primary  disease  or  idiopathic 
enlargement  of  the  thyroid  gland. 

McCarrison  considers  it  a  water-borne  infectious  disease 
the  exciting  factor  of  which  is  a  contagium  vivum  and 
suggests  that  it  belongs  to  the  colon  group  of  bacteria. 
Shepherd  also  in  his  report  in  1918  on  the  occurrence  of 
goiter  in  Canada  concludes  that  it  is  a  water-borne  infectious 
disease,  directly  comparable  to  typhoid. 

However,  most  of  the  scientific  investigators  of  this 
country  look  upon  goiter  as  a  deficiency  disease;  Marine 
has  been  emphasizing  this  point  since  1907.  As  has  been 
pointed  out: 

1.  lodin  is  essential  to  the  normal  thyroid  activity. 

2.  From  a  purely  biochemical  standpoint  any  substitu- 
tion for  iodin  destroys  the  physiologic  activity  of  the  thyroid 
hormone. 

3.  From  the  histologic  point  of  view  glandular  hyper- 
plasia  of  the  thyroid  is  due  to  a  deficiency  of  iodin. 

4.  The  physiologic  action  produced  by  thyroid  extract 
is  always  proportional  to  the  iodin  content. 

5.  In  animal  experimentation,  if  the  iodin  content  is 
maintained  at  or  above  T$  of  1  per  cent.,  no  anatomic 
changes  toward  goiter  formation  can  take  place. 

These  facts,  with  our  results  in  preventing  goiter  in 
school  girls  by  simply  keeping  the  thyroid  saturated  with 
iodin,  make  the  infectious  theory  at  once  untenable. 

These  facts  lead  to  the  conclusion  that  the  immediate 
or  exciting  cause  of  endemic  goiter  (hypertrophy  of  the 
thyroid  gland)  is  a  lack  of  iodin  in  the  organism.  This 
lack  of  iodin  may  be  relative  or  absolute.  The  remote 
or  fundamental  cause  of  goiter  is  quite  unknown. 


THE    PREVENTION   OF   SIMPLE    GOITER   IN   MAN          173 

PRACTICAL  APPLICATION  OF  THE  PRINCIPLE  OF  GOITER  PRE- 
VENTION 

In  the  practical  application  of  the  principle  of  pre- 
vention we  chose  the  public  schools  for  two  reasons:  (1) 
The  children  are  in  the  adolescent  age,  the  most  important 
period  in  the  development  of  goiter.  (2)  The  public  school 
group  furnishes  the  best  census  of  goiter  in  any  community, 
and  makes  it  possible  to  carry  out,  through  the  school 
organization,  the  most  expedient,  economic,  and  practical 
plan  of  prophylaxis  and  education. 

In  October,  1916,  we  explained  the  principle  of  the 
prevention  of  goiter  to  the  Superintendent  of  Schools  of 
Akron,  Dr.  H.  V.  Hotchkiss.  He  promised  the  full  support 
of  all  the  school  authorities  if  the  local  Medical  Society 
would  sanction  the  work.  After  this  idea  had  been  ex- 
plained to  the  Summit  County  Medical  Association  this 
body,  in  a  regular  session,  voted  to  send  the  following 
message  to  the  school  board:  "The  idea  of  prevention  of 
goiter,  as  outlined,  can  do  no  harm  and  may  do  good. 
We  are  in  favor  of  seeing  it  carried  out."  The  school 
board  authorized  the  superintendent  to  call  upon  Dr. 
Marine  and  myself  to  make  a  survey  of  goiter  among  the 
school  children  of  Akron  and  carry  out  any  plan  of  preven- 
tion we  saw  fit. 

In  April,  1917,  an  examination  for  thyroid  enlarge- 
ment was  made  of  all  the  girls  from  the  fifth  to  the  twelfth 
grades,  inclusive.  The  boys  were  not  examined  because 
of  the  relative  infrequency  of  goiter  in  boys.  The  result 
of  each  examination  was  recorded  on  a  special  individual 
card  which  on  one  side  had  space  for  the  pupil's  name, 
school,  age,  grade,  and  the  tabulations  of  four  thyroid 
examinations.  On  the  back  of  this  card  was  space  for  the 
record  of  eight  series  of  prophylactic  treatments,  which 


174  THE    THYROID    GLAND 

were  recorded  by  the  teacher  giving  the  treatment.  This 
goiter  card  was  attached  to  the  school  record  of  each  pupil 
and  was  transferred  with  the  pupil  whenever  transfer  to 
another  school  was  made.  In  no  other  way  could  we  have 
kept  track  of  so  many  cases  over  so  long  a  time. 

The  details  regarding  this  examination  and  the  plan 
for  carrying  out  the  treatment  were  then  published.  Only 
the  resultant  figures  will  be  given  here.  3872  girls  were 
examined,  with  the  following  results: 

Normal  thyroids,  1688,  or  43.6  per  cent. 

Slightly  enlarged  thyroids,  1931,  or  49.9  per  cent. 

Moderately  enlarged  thyroids,  246,  or    6.3  per  cent. 

Markedly  enlarged  thyroids,  7,  or    0.2  per  cent. 

Among  these  there  were  adenomas,      39,  or    1.0  per  cent. 

In  April,  1917,  the  first  prophylactic  treatment  was 
administered  to  more  than  1000  girls  who  had  elected  to 
take  it.  No  girl  was  urged,  and  no  one  was  permitted  to 
take  it  unless  she  had  a  written  permit  from  a  parent. 

In  November,  1917,  a  second  examination  of  all  girls 
from  the  fifth  to  twelfth  grades  inclusive  was  made,  in  all, 
4415  cases,  1772  of  which  were  new  records.  Of  the  2643 
old  records,  764  had  taken  the  prophylaxis  during  the 
preceding  six  months  and  1879  had  not.  As  was  published 
then,  there  was  not  a  single  case  in  which  a  normal  thyroid 
increased  if  the  pupil  was  taking  iodin,  while  among  those 
not  taking  iodin  26  per  cent,  of  those  marked  normal  at 
the  first  examination  showed  definite  enlargement — some 
already  having  developed  moderately  large  goiters.  Even 
more  than  a  prophylactic  action  was  shown  by  the  results 
— just  one-third  of  the  "small  goiters"  had  disappeared, 
and  one-third  of  the  "moderate  goiters"  had  decreased 
2  cm.  or  more. 

In  November,  1918,  a  third  examination  of  4277  girls 


THE   PREVENTION   OF   SIMPLE    GOITER   IN   MAN          175 

was  made.  In  October,  1919,  5520  individual  examinations 
were  recorded,  and  during  the  entire  period  9967  different 
girls  were  reported. 

EFFECT  OF  PROPHYLACTIC  TREATMENT 

The  prophylactic  treatment  as  carried  out  for  the 
past  three  years  in  the  Akron  schools  consists  of  the  admin- 
istration of  2  gm.  of  sodium  iodid,  given  in  0.2  gm.  doses 
daily,  for  ten  consecutive  school  days,  repeated  each  spring 
and  autumn.  The  general  data  of  the  pupils  not  taking 
the  treatment  are  given  in  Table  I,  and  of  those  taking  the 
treatment  in  Table  II.  Only  pupils  who  have  had  two  or 
more  consecutive  examinations  have  been  included  in  these 
tabulations.  A  considerable  number  of  pupils,  both  of 
those  who  have  been  taking  the  treatment  and  of  those 
who  have  not  been  taking  the  treatment,  have  been  omitted 
because  they  missed  one  examination,  although  otherwise 
their  records  were  complete;  2305  pupils  are  included  in  the 
tabulation  of  those  not  taking  treatment,  and  2190  in  the 
tabulation  of  those  taking  treatment. 

Furthermore,  properly  to  interpret  the  results  it  was 
necessary  to  take  into  consideration  the  length  of  time 
each  pupil  had  been  under  observation.  As  the  prophy- 
lactic treatment  was  given  at  intervals  of  six  months,  we 
have  used  this  interval  as  the  unit,  and  grouped  the  pupils 
according  to  the  periods  each  had  been  under  observation 
—i.  e.,  six,  twelve,  eighteen,  twenty-four,  or  thirty  months. 
The  results  of  only  three  groups,  those  with  normal,  slightly 
enlarged,  and  moderately  enlarged  thyroids,  are  included, 
because  the  fourth  group,  those  with  markedly  enlarged 
thyroids,  is  too  small.  A  comparison  of  the  two  tables 
brings  out  striking  differences  between  those  not  taking 
and  those  taking  iodin.  These  differences  are  manifested 


176  THE   THYROID   GLAND 

both  in  prevention  of  enlargement — prophylactic  effect, 
and  in  a  decrease  in  the  size  of  existing  enlargements — 
therapeutic  effect. 

Prevention. — The  preventive  value  of  the  treatment 
is  shown  hi  the  column  marked  "unchanged"  and  "in- 
creased." Taking  the  totals  for  the  periods  of  six  months 
each,  the  following  results  were  obtained.  Of  those  that 
were  normal  at  the  first  examination  and  did  not  take 
iodin,  347,  or  27.6  per  cent.,  had  enlarged  thyroids,  while 
of  those  that  were  normal  at  the  first  examination  and 
took  iodin  as  outlined,  2,  or  0.2  per  cent.,  had  enlarged 
thyroids.  These  two  instances  of  enlargement  were  in- 
vestigated. 

The  first  pupil,  aged  sixteen,  had  her  thyroid  examined 
and  classified  as  normal  on  May  2,  1917,  October  17,  1918, 
and  December  3,  1918.  At  the  examination  on  October 
15,  1919,  it  was  classified  as  slightly  enlarged.  This  girl 
had  taken  2  gm.  of  sodium  iodid  during  each  of  the  five 
possible  periods — May,  1917,  November,  1917,  May,  1918, 
December,  1918,  and  May,  1919.  A  special  examination 
was  made  on  January  13,  1920,  when  the  enlargement  of 
the  thyroid  was  verified.  That  this  enlargement  was 
acquired  rather  than  congenital  was  shown  by  the  absence 
of  a  pyramidal  process  of  the  thyroglossal  tract.  The 
tonsils  were  markedly  enlarged  and  abnormally  hyperemic. 
On  direct  questioning  we  were  informed  that  the  pupil 
was  subject  to  recurrent  attacks  of  tonsillitis.  There  was 
also  slight  enlargement  of  the  lymphoid  tissue  at  the  base 
of  the  tongue  and  in  the  nasopharynx,  and  the  general 
impression  was  that  of  a  neurotic  individual  with  general 
lymphoid  hyperplasia. 

The  second  girl,  aged  fifteen,  had  her  thyroid  first 
examined  and  classified  as  normal  on  November  27,  1918. 


THE   PREVENTION   OF   SIMPLE    GOITER   IN  MAN          177 

At  the  examination  on  October  16,  1919,  it  was  classified 
as  slightly  enlarged.  This  girl  had  taken  2  gm.  of  sodium 
iodid  during  each  of  the  two  available  periods,  November, 
1918  and  May,  1919.  A  special  examination  was  made 
January  13,  1920,  when  the  thyroid  enlargement  was 
verified.  Careful  inspection  revealed  the  presence  of 
Hutchinson  teeth,  depressed  nasal  arch,  and  interstitial 
keratitis.  We  considered  the  case  as  one,  of  neglected 
congenital  syphilis. 

Of  the  cases  classed  as  having  slightly  enlarged  thy- 
roids at  the  first  examination  and  not  taking  the  prescribed 
iodin,  127,  or  13.3  per  cent.,  underwent  further  enlarge- 
ment, while  among  those  taking  the  prescribed  treatment, 
only  three,  or  0.3  per  cent.,  underwent  further  enlargement. 
Two  of  these  three  were  re-examined  on  January  13,  1920, 
and  the  previous  finding  verified.  One  of  these  was  another 
case  of  chronic  infection  of  the  tonsils  with  recurrent 
attacks  of  tonsillitis  during  the  last  year.  In  the  second 
girl  superficial  inspection  failed  to  show  any  pathologic 
condition  to  account  for  the  enlargement.  The  third  girl 
was  not  present  for  examination.  These  five  cases  were 
the  only  instances  that  showed  enlargement  of  the  thyroid 
out  of  2190  pupils.  Of  the  2305  cases  not  taking  iodin,  495 
showed  thyroid  enlargement.  Of  the  group  with  small 
goiters,  taking  iodin,  659,  or  57.8  per  cent.,  returned  to 
normal,  while  of  the  same  group,  not  taking  iodin  at  school, 
134,  or  13.9  per  cent.,  returned  to  normal.  However,  we 
know  that  there  is  an  error  in  the  last  figure,  for  many 
cases  not  taking  iodin  under  the  school  jurisdiction  were 
taking  it  in  some  form  from  their  physician.  No  attempt 
has  been  made  to  detect  or  estimate  this  error. 

In  the  practical  application  of  the  preventive  treat- 
ment one  must  keep  in  mind  the  three  periods  when  simple 

12 


178  THE   THYROID   GLAND 

thyroid    enlargements    most    commonly    occur,    viz.:     (1) 
fetal  period;   (2)  adolescence,   and    (3)  pregnancy. 

1.  The   prevention   of   goiter   in   the   mother   and   the 
fetus  is  as  simple  as  the  prevention  of  goiter  which  develops 
during  adolescence.     Practically,  it  would  seem  that  the 
prevention  of  goiter  during  these  periods,  i.  e.,  1  and  3, 
is  properly  the  responsibility  of  individual  members  of  the 
medical    profession    supplemented    by    education    of    the 
public. 

2.  The  prevention  of  goiter  in  the  adolescent  period, 
on  the  other  hand,  should  be  a  public  health  measure  under 
state,  county,  or  municipal  control.     The  existing  systems 
of  organization  of  the  schools,  both  public  and  private, 
are  sufficient  to  handle  all  the  details  without  additional 
aid  or  expense.    Education  of  the  pupils  could  be  combined 
with  the  actual  administration  of  iodin  so  that  after  leav- 
ing school  they  could  continue  the  treatment  if  necessary. 
In  industrial  medicine  physicians  could  render  an  important 
service  in  this  direction.    As  thyroid  enlargement  is  approxi- 
mately six  times  as  frequent  in  girls  as  in  boys,  each  com- 
munity must  decide  whether  it  will  include  both  sexes  in 
prophylactic  measures;  as  it  must  also  decide  regarding 
the  ages  when  the  use  of  iodin  should  begin  and  end.     In 
this  climate  probably  the  maximum  of  prevention,  coupled 
with  the  minimum  of  effort,   would  be  obtained  by  the 
administration  of  iodin  between  the  ages  of  eleven  and 
seventeen  years.     As  applied  to  our  schools  this  would 
mean  beginning  with  the  fifth  grade. 

METHOD  AND  FORM  OF  ADMINISTRATION 

As  has  been  shown,  iodin  is  taken  up  by  the  thyroid 
gland  when  given  by  mouth,  by  inhalation,  or  by  external 
application.  And  it  makes  very  little  difference  from  a 


THE    PREVENTION    OF    SIMPLE    GOITER    IN   MAN  179 

scientific  point  of  view  what  form  of  iodin  is  used;  the 
thyroid  gland  will  take  up  iodin  from  the  most  stable  com- 
pound, i.  e.,  mercuric  iodid.  Weith  reports  favorable 
therapeutic  results  from  the  inhalation  of  iodin  secured 
by  the  suspension  in  the  schoolroom  of  a  wide-mouthed 
bottle  containing  10  per  cent,  of  tincture  of  iodin. 

It  has  been  suggested  by  Sloan  that  in  these  mildly 
goitrous  districts  a  mixture  of  small  amounts  of  sodium 
iodid  in  common  table  salt  could  be  made  which  would 
suffice  for  all  iodin  therapy.  However,  we  feel  that  the 
most  satisfactory  method  is  the  individual  oral  adminis- 
tration of  definite  small  amounts  of  some  salt  of  iodin, 
either  in  solution  or  tablet  form.  For  private  use  the  well 
known  U.  S.  P.  preparations,  syrup  of  ferrous  iodid  and 
syrup  of  hydriodic  acid,  are  excellent.  As  described  above, 
as  a  public  health  measure  we  used  2  gm.  of  sodium  iodid 
over  a  period  of  two  weeks  and  repeated  twice  yearly. 
This  dosage  has  prevented  enlargement  of  the  thyroid 
in  more  than  99  per  cent,  of  the  children  in  this  mildly 
goitrous  district. 

When  one  recalls  the  small  amount  of  iodin  required  to 
saturate  the  normal  thyroid  and  the  specific  affinity  of  this 
gland  for  iodin,  it  is  perfectly  obvious  that  only  very  small 
amounts  are  needed.  The  normal  thyroid  contains  about 
5  mgm.  of  iodin  per  gram  of  dried  gland;  25  to  30  mgm. 
is  the  total  storage  capacity.  From  this  it  is  clear  that  a 
few  milligrams  of  iodin  daily  over  a  longer  period  (a  month 
or  more)  would  produce  optimum  thyroid  effects. 

The  prevention  of  thyroid  enlargement  in  individuals 
with  other  diseases  or  in  those  residing  in  extremely  goit- 
rous districts,  as  in  some  glacial  valleys  of  Alaska  and  British 
Columbia,  and  in  certain  districts  of  the  Alps  and  Himalayas, 


180  THE    THYROID    GLAND 

might  require  larger  amounts  of  iodin  than  those  indicated 
above  as  sufficient  for  normal  individuals. 


POSSIBLE  ILL  EFFECTS 

As  was  stated  above,  there  was  some  anxiety  among 
medical  men  as  to  the  possible  ill  effects  of  giving  iodin 
promiscuously.  Some  men  anticipated  many  cases  of 
exophthalmic  goiter,  while  others  looked  for  an  outbreak 
of  iodid  rash.  The  actual  results  were  better  than  we  had 
hoped  for.  In  all  the  cases  taking  the  prescribed  2  gm. 
of  sodium  iodid  twice  yearly  there  was  not  a  single  instance 
of  exophthalmic  goiter  nor  any  evidence  of  a  nervous 
irritability  simulating  it.  In  all,  there  were  eleven  cases  of 
iodid  rash,  and  six  of  these  cases  were  so  mild  that  the  girls 
did  not  even  stop  the  treatment;  five  cases,  however,  caused 
sufficient  difficulty  for  the  treatment  to  be  stopped,  when 
the  rash  cleared  up  promptly. 

Both  of  these  possibilities  were  considered  and  men- 
tioned in  each  school.  In  all,  there  were  over  3000  different 
girls  taking  the  prophylactic  treatment,  many  of  whom 
took  it  for  three  years,  and  among  these  the  sum  total  of 
the  ill  effects  was  a  mild  rash  in  less  than  0.4  of  1  per  cent. 

THE  POSSIBILITY  OF  THE  ELIMINATION  OF  ENDEMIC  GOITER 
THROUGHOUT  THE  WORLD 

Following  the  publication  of  the  results  of  our  first 
year's  work  in  Akron  the  public  schools  of  Kent  and  Ravenna 
adopted  the  same  procedure,  and  in  1919  the  village  of 
Berea  began  the  prevention  of  goiter  through  the  schools 
on  the  same  plan.  In  the  spring  of  1920  we  completed  a 
survey  of  goiter  among  the  school  children  of  Warren,  Ohio, 
including  all  boys  and  girls  from  the  fifth  to  the  twelfth 


THE   PREVENTION   OF   SIMPLE   GOITER   IN   MAN          181 

grades,  inclusive.  As  the  incidence  of  thyroid  enlargement 
was  low — 24.4  per  cent,  in  girls  and  9.5  per  cent,  in  boys — 
we  advised  the  school  physician  and  nurse  that  we  con- 
sidered it  sufficient  in  this  vicinity  to  provide  each  school 
with  a  stock  solution  of  sodium  iodid  and  treat  each  goiter 
as  soon  as  it  was  detected.  This  method  has  been  in  opera- 
tion in  Warren  for  one  year  and  is  just  now  being  started 
in  Niles.  This  same  method  of  treatment  is  being  practised 
in  some  of  the  large  factories  of  Cleveland  where  many 
young  women  are  employed,  and  it  is  being  provided  in 
the  different  factories  of  the  National  Lamp  Works  hi 
eight  different  cities  of  the  United  States. 

It  is  interesting  to  note  that  in  the  spring  of  1918,  Prof. 
R.  Klinger,  of  Zurich,  Switzerland,  undertook  to  carry 
out  the  same  treatment  in  the  schools  there.  This  was 
soon  started  with  a  different  method  of  administration, 
but  practically  the  same  amounts  of  iodin  as  we  used  in 
Akron.  In  January,  1921,  Klinger  published  the  results 
of  the  first  sixteen  months'  treatment,  reporting  extra- 
ordinary results,  even  though  he  was  working  in  some 
schools  in  which  the  children  were  100  per  cent,  goitrous. 
Klinger 's  results  certainly  supply  striking  confirmation  of 
the  results  we  obtained  in  Akron.  It  is  even  more  gratify- 
ing to  know  that  recently  this  same  plan  for  the  prevention 
of  goiter  has  been  recommended  to  the  goiter  commission 
of  Switzerland  to  be  carried  out  as  a  public  health  measure 
throughout  the  whole  state,  the  most  noted  endemic  goiter 
nation  in  the  world. 

The  same  imagination  which  developed  the  practical 
application  of  the  principle  of  the  prevention  of  goiter 
can  now  see,  a  few  generations  hence,  the  closing  of  the 
chapters  on  endemic  goiter  and  cretinism  in  every  civilized 
nation  in  the  world. 


THE  THYROID  GLAND 


TABLE  I.— RECORD  OF  PUPILS  NOT  TAKING  PROPHYLACTIC 

TREATMENT 


Time 

Normal. 

Slightly  enlarged. 

Moderately  enlarged. 

under 
observa- 
tion. 

Un- 
altered. 

In- 
creased. 

Un- 
altered. 

In- 
creased. 

De- 
creased. 

Un- 
altered. 

In- 
creased. 

De- 
creased. 

months. 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

No. 

% 

6 

47 

50.0 

47 

50  0 

93 

69.4 

36 

26,9 

5 

37 

16 

69.6 

7 

30,4 

0 

0  0 

12 

420 

75  .  5 

136 

24.5 

251 

70.3 

35 

9.8 

71 

19.9 

17 

65.4 

8 

30.8 

1 

3.8 

18 

103 

65.2 

55 

34.8 

108 

74.5 

18 

12.3 

19 

13.1 

11 

57.9 

3 

15.8 

5 

26.3 

24 

186 

76.7 

41 

23.3 

106 

79.7 

8 

6.0 

19 

14.3 

9 

60.0 

3 

20.0 

3 

20,0 

30 

205 

75.1 

68 

24.9 

140 

73.7 

30 

15.8 

20 

10.5 

4 

66.7 

0 

0.0 

2 

33.3 

TABLE  II.— RECORD  OF  PUPILS  TAKING  PROPHYLACTIC 
TREATMENT 


Time 


Normal. 


Slightly  enlarged. 


Moderately  enlarged. 


under 
observa- 
tion, 
months. 

Un- 
altered. 

In-             Un- 
creased.     altered. 

In- 
creased. 

De-             Un- 

creased.     altered. 

In- 
creased. 

De- 
creased. 

No. 

% 

No. 

%     No. 

% 

No. 

% 

No. 

%     ;NO. 

% 

No. 

% 

No. 

% 

6 

12 
18 
24 
30 

17 
344 
73 
184 

288 

94.4 
99.7 
100.0 
100.0 
100.0 

1 

1 
0 
0 
0 

5.6     54 
0.3    187 
0.0     72 
0.0     72 
0.0     92 

69.2 
45.5 
52.3 
37.9 
28.5 

1 
0 
1 
1 
0 

1.3 
0.0 
0.7 
0.5 
0.0 

23 
224 
64 
117 
231 

29.5     9 
54.5    10 
46.7      7 

6i.  q    2 

71.  a    i 

81.8 
23.8 
28.0 
7.7 
2.6 

0 
0 
0 
0 
0 

0.0 
0.0 
0.0 
0.0 
0.0 

2 

32 
18 
24 

38 

18.2 
76.2 
72.0 
92.3 
97.4 

TABLE  III.— SUMMARY— RECORDS  OF  PUPILS  TAKING  AND 
NOT  TAKING  PROPHYLACTIC  TREATMENT 


Taking. 

Not  taking. 

Totals. 

Per  cent. 

Totals. 

Per  cent. 

Normal: 

906 
2 

477 
3 
659 

29 
0 
114 

99.8 
0.2 

41.9 
0.3 

57.8 

20.3 
0.0 
79.7 

910 
347 

698 
127 
134 

57 
21 
11 

72.4 
27.6 

72.8 
13.3 
13.9 

64.0 
23.6 
12.4 

Increased. 

Slightly  enlarged: 
Unchanged 

Increased  

Moderately  enlarged: 

Decreased  

Total  

2190 

2305 

BIBLIOGRAPHY 

Adami,  J.  G.:    On  the  Etiology  and  Symptomatology  of  Goiter,  Montreal 

Mod.  Jour.,  1900,  xxix,  1-17. 
Ashmead,  A.  S. :  Note  on  the  Etiology  and  Natural  Cure  of  Goiter,  New  York 

Med.  Jour.,  1895,  Pt.  1,  1344. 
Barton,  B.  S. :  A  Memoir  Concerning  the  Disease  of  Goiter  as  It  Prevails  in 

Different  Parts  of  North  America,  1900. 
Brendel,  E.  P.,  and  Helm,  H.  M.:    Goiter  Among  Drafted  Men  from  the 

Northwest,  Arch.  Int.  Med.,  1919,  xxiii,  61. 


THE    PKEVENTION    OF    SIMPLE    GOITER   IN   MAN  183 

Clark,  T.,  and  Pierce,  C.  C.:  Endemic  Goiter — -Its  Possible  Relation  to  Water 

Supply,  Public  Health  Reports,  1914,  xxix,  939. 
Crotti,  A.:  Thyroid  and  Thymus,  1918. 

Dock,  G.:   Goiter  in  Michigan,  Trans.  Assoc.  Amer.  Phys.,  1895,  x,  101. 
Gull,  W. :    A  Cretinoid  State  Supervening  in  Adult  Life  in  Woman,  Trans. 

London  Clinical  Society,  1874,  vii,  180. 

Hall,  D.  C. :  The  Prevalence  of  Goiter  in  the  Northwest,  Based  on  the  Exam- 
ination of  3339  Students  Entering  the  University  of  Washington,  North- 
west Med.,  1914,  n.  s.  vi,  189. 

Halsted,  William  S. :  Johns  Hopkins  Hosp.  Report,  1896,  373. 
Hirsch,  A.:  Handbook  of  Geographical  and  Historical  Pathology,  1885, ii,  121. 
Holder,  A.  B.:  Goiter:  A  New  Habitat,  New  Orleans  M.  and  S.  J.,  1912,  v, 

254. 

Horsley,  Sir  Victor:  Experimental  Myxedema  in  Monkeys,  Proc.  of  Royal 
Society,  London,  1886,  xl,  6;  Proc.  of  Royal  Society,  London,  1884-5, 
xxxviii,  5;  Brit.  Med.  Jour.,  1892,  i,  215  and  1113. 
Hunziker,  H.:   Goiter  in  Switzerland,  Corresp.-Blatt.  f.  Schweitzer  Aerzte, 

1918,  xlviii,  247. 

Kendall,  E.  C. :  The  Active  Constituent  of  the  Thyroid,  Its  Isolation,  Chem- 
ical Nature  and  Physiologic  Action,  Collected  Papers  of  the  Mayo  Clinic, 
1916,  513.  The  Thyroid  Hormone  and  Its  Relation  to  Other  Ductless 
Glands,  Endocrinology,  1918,  ii,  81.  Isolation  of  the  lodin  Compound 
which  Occurs  in  the  Thyroid,  J.  Biol.  Chem.,  1919,  xxxix,  125.  The 
Physiologic  Action  of  Thyroxin,  Endocrinology,  1919,  iii,  156. 
Kerr,  William  J.:  A  Preliminary  Survey  of  the  Thyroid  Gland  Among  2182 

Recruits  at  Camp  Lewis,  Washington,  Arch.  Int.  Med.,  1919,  xxiv,  347. 
Klinger,  R.:    Prevention  of  Goiter  in  School  Children  in  Zurich,  Schweiz. 

Med.  Woch.,  1921,  Ii,  12. 

McCarrison:  Etiology  of  Endemic  Goiter,  London,  1911. 
Marine,  D.:  On  the  Occurrence  and  Physiological  Nature  of  Glandular 
Hyperplasia  of  the  Thyroid,  etc.,  Bull.  Johns  Hopkins  Hosp.,  1907, 
xviii,  359.  Further  Observations  on  Goiter,  Its  Prevention  and  Cure, 
Jour.  Exp.  Med.,  1914,  xix,  70.  Quantitative  Studies  on  the  In  Vivo 
Absorption  of  lodin  by  Dog's  Thyroid  Glands,  Jour.  Biol.  Chem.,  1915, 
xxii,  547.  Physiology  of  the  Thyroid  Gland,  Ohio  State  Med.  Jour.,  1920, 
xvi,  735. 

Marine,  D.,  and  Kimball,  O.  P.:  The  Prevention  of  Simple  Goiter  in  Man: 
1.  J.  Lab.  and  Clin.  Med.,  1917,  iii,  40.  2.  Arch.  Int.  Med.,  1918,  xxii, 
41.  3.  J.  A.  M.  A.,  1919,  Ixxiii,  1873.  4.  Arch.  Int.  Med.,  1920,  xxv, 
661. 

Marine,  D.,  and  Lenhart,  C.  H.:  Colloid  Glands  (Goiter),  Their  Etiology  and 
Physiological  Significance,  Bull.  Johns  Hopkins  Hosp.,  1909,  xx,  131. 
Further  Observations  on  the  Relation  of  lodin  to  the  Structure  of  the 
Thyroid  Gland  in  Sheep,  Dog,  Hog,  and  Ox,  Arch.  Int.  Med.,  1909,  iii, 
66.  Effects  of  the  Administration  or  the  Withholding  of  lodin-containing 
Compounds  in  Normal,  Colloid  or  Active  Hyperplastic  Thyroids  of  Dogs, 
Arch.  Int.  Med.,  1909,  iv,  253.  The  So-called  Thyroid  Carcinoma  in 
Brook  Trout,  J.  Exper.  Med.,  1910,  xii,  311.  Further  Observations  on 
the  So-called  Thyroid  Carcinoma  of  the  Brook  Trout,  and  Its  Relation  to 
Endemic  Goiter,  J.  Exper.  Med.,  1911,  xiii,  455. 


184  THE    THYROID    GLAND 

Marine,  D.,  and  Williams,  W.  W.:  Relations  of  lodin  to  the  Structure  of  the 

Thyroid  Gland,  Arch.  Int.  Med.,  1908,  i,  345. 
Munson,  E.  L. :  The  Occurrence  of  Goiter  Among  the  Indians  of  the  United 

States,  N.  Y.  Med.  Jour.,  1895,  Ixii,  513. 
Plummer,  H.  S. :    The  Function  of  the  Thyroid,  Normal  and  Abnormal. 

Collected  Papers  of  the  Mayo  Clinic,  1916,  528. 
Reclus,  E.:  Universal  Geography,  vol.  ii,  68;  vol.  iii,  111;  vol.  v,  130. 
Schittenhelm,  A.,  and  Weichardt,  W.r  Der  endemische  Kropf  mit  besonder 

Beriicksichtigung  des  Vorkommens  in  Konigreich  Bayern,  Berlin,  1912. 
Shepherd,  F.  J.:   Enlargement  of  Thyroid  Gland  or  Goiter,  Report  of  Com- 
mission of  Conservation  of  Canada,  December,  1918. 
Sloan,  H.  G.:  Use  of  Iodized  Table  Salt  to  Prevent  Goiter,  Ohio  State  M. 

J.,  1921,  xvii,  172. 
Smith,  F.  M.:    Statistical  Study  of  Simple  and  Toxic  Goiter  at  Jefferson 

Barracks,  J.  A.  M.  A.,  1919,  Ixxii,  471. 
Springle,  J.  A.:  Goiter,  Its  Etiology  and  Incidence  in  the  District  of  Montreal, 

Montreal  Med.  Jour.,  1899,  xxviii,  909. 
Weith:  Goiter  and  lodin  in  the  School,  Cor.  Bl.  f.  Schweiz.  Aerzte,  1919,  xlix, 

1474. 
Zueblin,  E.:    Experimental  Pathology  of  Goiter,  N.  Y.  Med.  Jour.,  1916, 

civ,  1186. 


SURGERY  VS.  JT-RAY  IN  THE  TREATMENT  OF  HYPER- 
THYROIDISM1 

GEORGE  W.  CHILE 


HYPERTHYROIDISM  (C.  H.  Mayo)  seems  a  more  fitting 
name  for  a  disease  whose  chief  characteristic  is  a  super- 
normal activation  of  the  thyroid  gland  than  exophthalmic 
goiter,  a  term  which  signifies  but  one  of  the  features  of  this 
complex  syndrome. 

That  great  student  of  the  thyroid  gland,  Marine,  has 
stated  that  in  the  literature  the  cure  of  hyperthyroidism 
has  been  credited  to  each  of  239  drugs  and  other  methods 
of  treatment.  From  among  all  the  opinions  in  favor  of 
one  or  another  of  these  many  therapeutic  measures,  the 
verdict  in  favor  of  physiologic  rest,  by  itself  alone,  or  com- 
bined with  other  methods,  is  practically  unanimous;  and 
only  two  other  methods  of  treatment  have  emerged  as 
worthy  of  particular  consideration — surgery  and  the  x-rays. 

To  those  who  have  not  noted  the  increasing  importance 
which  is  assigned  by  many  physicians  and  surgeons  as  well 
as  by  roentgenologists  to  the  use  of  the  x-rays  in  the  treat- 
ment of  hyperthyroidism,  a  study  of  the  literature  is  illumi- 
nating. A  brief  survey  reveals  105  papers,  hi  which  the 
favorable  action  of  the  x-ray  on  hyperthyroidism  is  reported. 
Ludin1  made  a  collection  of  208  articles  on  this  subject. 

The  general  conclusions  of  the  majority  of  these  writers 
may  be  summarized  briefly  as  follows: 

1  Reprinted  from  3.  A.M.  A.,  1921,  Ixxvii,  1324. 

2  Ludin,  Centralb.  f.  d.  Grenz.  d.  Med.  u.  Chir.,  1915,  xviii,  205-235. 

185 


186  THE    THYROID    GLAND 

1.  "It  is  utterly  impossible  to  draw  conclusions  from 
any  collection  of  statistics  on  this  subject,   because  the 
cases  reported  show  such  a  variation  and  such  indefinite 
technic  that  the  reduction  of  the  statistics  would  give  us 
nothing  accurate  by  which  we  could  judge  future  results."1 

2.  All  writers  agree  that  the  pulse-rate  is  nearly  always 
reduced  promptly;  that  usually  the  tremor  and  nervous 
symptoms   are   relieved   at   once;   that   the   body   weight 
usually  begins  to  increase  immediately. 

3.  There  is  a  divergence  of  opinion  regarding  the  effect 
upon  the  gland  itself,  as  the  experience  of  different  writers 
appears  to  have  varied  widely. 

Seymour  expresses  the  opinion  of  most  advocates  of 
the  re-ray  treatment  of  hyperthyroidism  in  his  summary 
of  its  advantages:2 

"1.  There  are  no  fatalities. 

"2.  There  is  no  resulting  scar,  as  after  operation. 

"3.  It  does  not  interfere  with  the  patient's  occupation. 

"4.  It  is  painless  and  causes  very  little  inconvenience  to 
the  patient. 

"5.  If  unsuccessful,  an  operation  may  be  done  with  less 
work  because  of  the  favorable  action  of  the  x-ray  on  the 
thymus  gland." 

Means  and  Aub,  in  a  more  recent  report  from  the 
Massachusetts  General  Hospital,3  conclude  that  "The 
chance  of  cure  in  exophthalmic  goiter  is  as  good  with  the 
Roentgen  ray  as  with  surgery  in  groups  of  equal  toxicity; 
and  that  this  being  true  the  former  method  is  preferable, 
for  the  danger  of  a  fatal  outcome  is  less."  These  authors 
believe  that  surgery  should  be  employed  only  after  the 
x-ray  and  other  methods  have  failed. 

1  Pfahler,  G.  E.,  and  Zulick,  J.  D.,  A.  J.  Roentgenol,  1916,  iii,  63-72. 

2  Seymour,  Malcolm,  Boston  M.  and  S.  J.,  1916,  clxxv,  568-569. 

3  Means,  J.  H.,  and  Aub,  J.  C.,  Archiv.  Int.  Med.,  1919,  xxiv,  645-677. 


SURGERY   VS.    X-RAY   IN   HYPERTHYROIDISM  187 

On  the  other  hand,  we  find  Hildebrand1  concluding 
from  his  personal  experience  with  thirteen  cases  that  in  none 
had  he  observed  any  real  lasting  effect;  and  that  when  the 
cases  finally  came  to  operation  the  muscles,  gland  capsule, 
and  the  gland  had  become  so  adherent  that  the  difficulty 
and  hazard  of  the  operation  were  increased;  moreover, 
there  were  signs  of  necrosis  in  the  superficial  layers  of  the 
gland.  He  reports  also  that  fatal  cases  of  acute  swelling 
of  the  gland,  "thyroidismus,"  have  resulted  from  x-ray 
treatment. 

In  discussing  a  paper  by  Boggs2  Waters  made  the 
following  comments: 

"Before  attempting  the  treatment  of  exophthalmic  goi- 
ter or  hyperthyroidism  with  x-rays  it  is  vitally  necessary: 

"1.  That  it  be  known  what  histologic  change  takes 
place  in  the  gland; 

"2.  That  the  superficial  and  deep  structures  of  the 
skin  be  not  injured  by  the  x-rays; 

"3.  That  the  effect  upon  the  vagus,  sympathetic  gang- 
lion, and  parathyroids  be  definitely  known; 

"4.  That  it  be  known  what  effect  upon  the  thyroid 
gland  is  desired,  that  is,  stimulating  or  inhibiting. 

"  Therefore,  until  these  points  are  proved  the  work  is 
being  done  not  only  unscientifically,  but  with  extreme 
danger." 

In  1916,  Berkman  reported  from  the  Mayo  Clinic3  that 
although  in  their  experience  the  results  of  x-ray  treatment 
were  good,  they  were  temporary;  that  the  results  were 
delayed  and  required  many  repetitions  of  treatment;  that 
practically  no  dependable  beneficial  results  were  obtained 
in  less  than  a  month;  and  that  in  the  more  serious  cases 

1  Hildebrand,  Otto,  Archiv.  Klin.  Chir.,  1919,  cxi,  1-70. 

2  Boggs,  Russell  H.,  A.  J.  Roentgenol.,  1919,  vi,  613-619. 

3  Berkman,  D.  M.,  St.  Paul  Med.  Jour.,  1916,  xviii,  300-303. 


188  THE    THYROID   GLAND 

"the  excitement  and  mobilization  incident  to  oxray  treat- 
ment usually  offset  whatever  early  benefits  may  be  received." 

In  a  recent  article  C.  H.  Mayo1  writes: 

"With  x-ray  treatment  remissions  may  occur  just  as 
remissions  occur  without  treatment  or  with  several  other 
methods  of  treatment.  Our  experience  has  been  failure 
or  but  temporary  benefit.  It  is  possible  that  the  ray  treat- 
ment may  destroy  the  gland  and  produce  hypothyroidism. 
It  is  difficult  to  regulate  the  dosage,  and  its  use  adds  to 
the  difficulties  of  operation." 

Most  writers  agree  as  to  the  beneficial  effect  of  the 
x-rays  in  adolescent  hyperthyroidism;  and  many  consider 
that  this  beneficial  effect  is  due  principally  to  the  action 
of  the  x-rays  upon  the  hyperplastic  thymus,  which,  accord- 
ing to  some  reporters,  is  present  in  90  per  cent,  of  the  cases 
of  exophthalmic  goiter.  In  our  own  experience  we  have 
never  had  a  single  case  of  hyperthyroidism  in  which  we 
had  reason  to  consider  an  enlarged  thymus  a  complicating 
factor.  At  the  Mayo  Clinic  a  study  of  100  necropsies  of 
fatal  cases  of  exophthalmic  goiter  was  made  to  determine 
the  possible  relation  between  the  thymus  in  adults  and 
exophthalmic  goiter.2  The  investigators  concluded  that  a 
hypertrophic  thymus  is  present  in  all  exophthalmic  goiter 
cases  under  forty  years  of  age,  and  in  half  of  those  over 
forty  years  of  age.  "Hypertrophy  of  the  thymus  is  inversely 
proportional  to  the  age  of  the  patient  and  directly  propor- 
tional to  the  duration  of  the  disease." 

As  to  the  cause  and  effect  of  the  enlarged  thymus, 
however,  these  reporters  make  the  following  comment: 

"Our  records  in  general  show  that  the  most  severe 
acute  cardiac  damage  is  seen  in  those  violent  intoxications 

1  Mayo,  C.  H.,  Surg.,  Gyn.,  and  Obst.,  1921,  xxxii,  209-213. 

2  Blackford,  J.  M.,  and  Freligh,  W.  P.,  Collected  Papers  of  the  Mayo 
Clinic,  1916,  viii,  507-512. 


SURGERY   VS.   X-RAY   IN   HYPERTHYROIDISM  189 

in  which  the  onset  occurs  after  the  age  of  forty;  that  is, 
in  the  'menopause'  group.  These,  as  a  rule,  have  a  small 
thymus  or  no  thynms.  In  every  case  of  cardiac  damage 
hi  which  a  thymus  was  found  there  was  definite  parenchyma- 
tous  hypertrophy  in  the  thyroid  with  no  demonstrable 
thymus.  .  .  .  The  findings  indicate  that  a  thyrnic  hyper- 
trophy and  lymphatic  hyperplasia  should  be  considered 
as  a  result  rather  than  as  a  cause  of  the  intoxication  in 
hyperplastic  or  non-hyperplastic  goiter.  Hypertrophy  of 
the  thymus  probably  depends  on  the  presence  of  vestigial 
tissue  at  the  onset  of  disease  which  may  regenerate  under 
toxic  stimulation." 

Several  writers,  notably  Means  and  Aub,1  base  their 
judgment  as  to  the  efficiency  of  the  x-ray  treatment  of 
hyperthyroidism  on  its  effect  on  the  basal  metabolism. 
In  Lakeside  Hospital  Dr.  Christie  has  made  a  series  of 
comparative  studies  of  the  effects  of  the  x-rays,  of  ligation, 
and  of  thyroidectomy  on  the  basal  metabolism.  He  has 
found  that  bilateral  partial  thyroidectomy  reduces  the 
metabolism  more  markedly  and  more  promptly  than  either 
the  x-rays  or  ligation;  and  that  the  x-rays  reduce  the 
metabolism  more  than  ligation.  Since  ligation  is  employed 
only  as  a  preliminary  step  to  thyroidectomy,  it  need  not  be 
considered  in  'this  discussion.  On  the  other  hand,  since 
Dr.  Christie's  findings  appear  to  show  that  thyroidectomy 
exerts  the  greater  immediate  curative  effect,  it  becomes 
necessary  to  determine  whether  or  not  there  are  other 
considerations  which  should  prohibit  the  employment  of 
thyroidectomy  in  preference  to  the  x-rays.  To  determine 
this  it  is  necessary  to  compare  thyroidectomy  and  x-ray 
treatment  as  to  (a)  the  resultant  discomfort;  (6)  the  re- 
sultant period  of  disability;  (c)  the  immediate  mortality, 

1  Loc.  tit. 


190 


THE    THYROID    GLAND 


and  (d)  the  end-results.  It  is  significant  to  note  that  many 
cases  that  came  to  operation  have  had  z-ray  treatment 
(Figs.  58,  59). 

Discomfort. — In  Lakeside  Hospital  in  all  severe  cases  of 
hyperthyroidism  the  operation  is  performed  in  the  patient's 


Fig.  58. — Burn  due  to  treatment  of  goiter  with  x-rays. 

room,  without  moving  the  patient  from  bed;  the  patient 
is  protected  from  worry,  anxiety,  and  fear  by  tactful  man- 
agement; no  discomfort  follows  the  preliminary  ligation; 
and  there  is  relatively  little  discomfort  after  the  thy- 


SURGERY    VS.    X-RAY    IN    HYPERTHYROIDISM  191 

roidectomy.  It  follows  that  this  plan  of  surgical  manage- 
ment produces  no  greater  subjective  disturbance  of  the 
patient — probably  less  in  the  severe  case — than  results 
from  transportation  to  and  from  the  x-ray  treatment  room. 
Period  of  Disability. — In  a  recent  series  of  500  thy- 
roidectomies  the  average  stay  in  the  hospital  before  liga- 
tion  was  four  and  three-fourths  days,  after  ligation,  from 
three  to  five  days.  The  average  stay  in  the  hospital  before 


r 


i 


Fig.  59. — Burn  due  to  the  x-ray  treatment  of  the  thyroid  gland  after  partia 

thyroidectomy. 

thyroidectomy  was  four  and  one-half  days,  after  thy- 
roidectomy, thirteen  days.  The  total  hospital  period, 
therefore,  averaged  twenty-five  and  one-fourth  days — 
broken  by  the  period  at  home  between  the  ligation  and 
the  thyroidectomy. 

In  the  Massachusetts  General  Hospital  series  reported 
by  Means  and  Aub1  no  data  are  given  from  which  one  may 

1  Loc.  cit. 


192  THE    THYROID    GLAND 

judge  the  length  of  stay  in  the  hospital  required  for  each 
oxray  treatment  or  group  of  treatments.  Nevertheless,  it 
is  obvious  that  the  total  loss  of  time  and  the  inconvenience 
necessitated  by  repeated  visits  to  the  hospital  exceed  that 
occasioned  by  surgical  treatment  alone. 

Mortality. — Among  our  last  500  thyroidectomies  there 
were  5  deaths,  a  mortality  rate  of  1  per  cent.;  among 
the  last  500  ligations  there  were  2  deaths,  a  mortality  rate 
of  0.4  per  cent.  Our  records  show  a  series  of  331  consecu- 
tive thyroidectomies  and  145  consecutive  ligations — that 
is,  476  consecutive  thyroid  operations  without  a  death. 
And  among  thyroid  operations  for  exophthalmic  goiter  the 
records  show  a  series  of  227  consecutive  thyroidectomies 
and  180  consecutive  ligations,  that  is,  407  consecutive 
thyroid  operations  for  hyperthyroidism  without  a  death. 
These  series  are  not  made  up  of  selected  cases.  No  patient 
was  rejected,  although  the  series  included  patients  in  every 
stage  of  hyperthyroidism,  some  with  edema  of  the  extremities 
and  ascites. 

As  we  have  stated  above,  we  have  found  in  the  litera- 
ture no  statistics  which  give  a  basis  for  comparison,  although 
it  is  obvious  that  the  immediate  mortality  of  o>ray  treat- 
ment is  hardly  to  be  considered;  although,  from  among  the 
cases  treated  by  o>ray,  a  goodly  number,  probably  several 
per  cent.,  die  while  taking  the  treatments. 

Our  statistics,  however,  show  that  the  operative  risk 
in  cases  of  hyperthyroidism,  under  the  type  of  surgical 
management  indicated  above,  may  be  largely  disregarded. 

End-results. — It  is  too  early  to  report  on  the  end- 
results  of  our  recent  series,  as  at  least  three  years  should 
elapse  before  the  end-results  may  be  considered  as  stabilized ; 
but  it  is  conceded  that  surgical  reduction  is  altogether 
the  most  curative  method. 


SURGERY   VS.    X-RAY   IN   HYPERTHYROIDISM  193 

CONCLUSION 

From  a  study  of  the  evidence  offered  by  those  who 
advocate  the  z-ray  treatment  of  hyperthyroidism  and  a  con- 
sideration of  our  own  experience  we  believe  that  the  surgical 
treatment  of  hyperthyroidism  combined  with  physiologic 
rest  yields  the  most  favorable  results.  Heretofore  the  only 
valid  objection  to  surgical  treatment  has  been  the  mortality; 
but  surgery  now  undertakes  every  case;  the  mortality  is 
practically  eliminated;  much  time  is  saved  and  a  more 

certain  cure  is  achieved. 
13 


PREOPERATIVE  MANAGEMENT  OF  EXOPHTHALMIC 

GOITER 

W.  R.  GOFF  AND  E.  O.  RUSHING 


THE  preoperative  treatment  of  patients  having  exoph- 
thalmic goiter  is  very  important  because  they  are  so  ex- 
quisitely sensitive  and  nervous  that  even  the  slightest 
disturbing  element  in  their  treatment  may  seriously  impair 
their  already  lowered  thresholds. 

INTRODUCTION  OF  THE  PATIENT  TO  HOSPITAL  ACTIVITIES 

It  must  be  remembered  that  most  patients  have  never 
before  been  in  contact  with  hospital  life.  Therefore  it  is 
necessary  to  eliminate  every  possible  source  of  anxiety 
and  worry  which  may  be  occasioned  by  the  hospital  routine. 
In  fact,  the  treatment  begins  before  the  patient  arrives  at 
the  hospital,  for  care  is  taken  to  make  sure  that  the  patient's 
room  is  ready  on  his  arrival  so  that  he  may  be  immediately 
conducted  to  it,  for  waiting  is  poorly  tolerated.  The  nurses 
and  attendants  are  instructed  to  receive  their  patients  with 
the  greatest  consideration  and  to  win  their  confidence  as 
quickly  as  possible. 

The  patient  is  weighed  and  put  to  bed,  and  is  not  allowed 
to  get  out  of  bed  again  until  after  the  operation.  One  or 
two  relatives  or  friends  may  remain  with  him  during  the 
remainder  of  the  day  of  arrival,  but  after  this  but  one  visitor 
is  admitted  at  a  time,  to  remain  for  thirty  minutes  only. 
No  formal  history  is  taken  or  examinations  made  on  the 
day  of  admission.  The  ward  physician  makes  a  social  call 

and  only  in  an  indirect  way  enters  into  conversation  con- 

195 


196  THE   THYROID   GLAND 

cerning  the  illness.  Nothing  is  said  concerning  the  opera- 
tion. We  recently  saw  a  crisis  develop  in  one  case  because 
when  the  patient  asked  to  wear  her  own  nightgown  the 
nurse  told  her  she  should  put  on  the  operating-room  clothes. 

PRELIMINARY  EXAMINATIONS,  TESTS,  AND  THERAPY 

On  the  second  day  a  thorough  history  is  taken,  and 
if  the  patient  is  not  tired  by  this,  the  routine  physical 
examination  is  made.  The  utmost  care  is  taken  to  pre- 
vent the  patient  from  becoming  overtired  and,  upon  the 
first  evidence  of  fatigue,  all  activities  cease,  to  be  resumed 
later. 

Special  attention  is  given  to  the  heart  because  acute 
myocardial  failure  is  frequently  encountered  in  exophthalmic 
goiter  cases.  If  any  sign  of  myocarditis  is  present  a  course 
of  treatment  is  begun  at  once — 20  minims  or  less  of  the 
tincture  of  digitalis  every  four  hours  for  from  eight  to  twelve 
doses.  If  this  is  not  sufficient  for  the  maximum  restora- 
tion of  the  myocardium,  a  second  preoperative  course  of 
digitalis  may  be  given  after  a  few  days  of  complete  rest. 

The  renal  function  is  tested  routinely  by  the  Mosenthal 
method.  This  method  is  preferred  because  it  is  reliable, 
it  does  not  interfere  with  other  tests,  and  it  does  not  disturb 
the  patient  as  do  some  of  the  other  nephritic  tests  which 
depend  upon  the  secretion  of  dyes  injected  with  a  needle. 

The  test  is  made  as  follows:  At  8  A.  M.  the  patient 
voids,  the  specimen  being  discarded.  Breakfast  is  then 
given,  lunch  at  12,  and  dinner  at  6  p.  M.  Moderate  amounts 
of  fluids  are  taken  at  mealtime  only.  Specimens  of  urine 
are  collected  at  10  A.  M.,  12  noon,  at  2,  4,  6,  and  8  p.  M. 
From  8  P.  M.  to  8  A.  M.  the  specimens  are  collected  in  one 
container,  the  amount  and  specific  gravity  of  each  urina- 
tion being  first  ascertained.  Normally  the  10  A.  M.  and  the 


PREOPERATIVE  MANAGEMENT  OF  EXOPHTHALMIC  GOITER       197 

2,  4,  and  8  P.  M.  specimens  will  be  large  in  amount  and 
low  in  specific  gravity;  the  12  noon  and  6  P.  M.  specimens 
will  be  smaller  in  amount  and  high  in  specific  gravity; 
the  night  specimen  will  be  larger  in  amount,  but  high  in 
specific  gravity.  If  nephritis  is  present,  however,  the  speci- 
mens will  tend  to  be  the  same  in  amount  and  in  specific  grav- 
ity. If  nephritis  is  suspected,  the  phenolsulphonephthalein 
test  is  made  by  intramuscular  injection.  If  the  excretion 
is  low,  operation  is  deferred  until  the  output  is  raised  to 
a  safe  level  by  treatment,  which  consists  of  rest  hi  bed, 
the  administration  of  large  quantities  of  water  by  the 
mouth,  subcutaneous  infusions  of  novocain — ^  per  cent. 
(Bartlett) — the  administration  of  glucose  and  sodium 
bicarbonate  per  rectum  in  a  10  per  cent,  solution  and  the 
elimination  of  the  amount  of  food  intake,  particularly  of 
protein  and  salt,  to  a  minimum.  Frequently  the  patient 
is  restricted  to  a  milk  diet.  If  there  is  a  retention  of  fluids 
with  edema,  together  with  renal  insufficiency,  hot  packs 
are  used  as  in  the  treatment  of  advanced  nephritis.  With 
this  treatment  the  systolic  blood-pressure  is  frequently 
reduced  from  30  to  40  points. 

Exophthalmic  goiter  patients  frequently  suffer  from 
insomnia.  To  avoid  this  thirty  grains  of  sodium  bromid 
are  given  every  evening  at  eight  o'clock.  Usually  after  one 
or  two  nights  in  the  hospital  the  patients  relax  and  sleep 
well. 

In  order  to  prevent  any  systemic  disturbance  which 
may  result  from  the  sudden  diminution  of  the  thyroid 
secretion  by  thyroidectomy  two  grains  of  thyroid  extract 
are  given  on  the  evening  before  and  on  the  morning  of 
operation. 

The  cycles  of  vomiting,  tachycardia,  restlessness,  delir- 
ium, etc.,  usually  called  hyperthyroidism,  are  now  believed 


198  THE    THYROID    GLAND 

to  be  due  to  an  intracellular  acidosis  which  can  ordinarily  be 
cleared  up  by  active  treatment  consisting  of  measures  which 
restore  the  internal  respiration.  This  treatment  comprises 
the  digitalization  of  the  heart  by  the  administration  of  20 
minims  or  less  of  the  tincture  of  digitalis  every  four  hours 
until  eight  to  twelve  doses  have  been  given,  blood  transfu- 
sion, and  subcutaneous  infusion  of  from  3000  to  5000  c.c. 
of  normal  saline  solution  every  twenty-four  hours. 

PREOPERATIVE  ROUTINE 

Because  of  the  nervousness  of  these  patients  and  their 
poor  tolerance  for  suspense  they  are  usually  not  told  when 
the  operation  is  to  be  performed;  in  fact,  if  possible,  the 
subject  of  operation  is  altogether  avoided,  and  stress  is 
laid  upon  treatment.  In  order  to  prevent  the  patient 
from  knowing  exactly  when  the  operation  is  to  take  place 
the  following  routine  is  carried  out  daily  for  several  days 
beforehand. 

The  operating-room  clothes  are  put  on  usually  the  day 
after  admission.  Some  kind  of  explanation  has  to  be  given 
for  each  move  to  satisfy  the  curiosity  of  the  patient.  He 
is  told  the  pneumonia  jacket  and  leggings  are  kept  on  to 
insure  an  even  temperature  of  the  body,  etc. 

A  hypodermic  injection  of  sterile  water  is  given  every 
morning  about  eight  and  breakfast  is  deferred. 

At  nine  each  morning,  before  the  patient's  breakfast  is 
served,  the  anesthetist  takes  a  nitrous  oxid-oxygen  machine 
to  the  bedside  and,  after  explaining  to  the  patient  that  she 
is  going  to  give  him  some  oxygen  for  his  heart,  the  mask 
is  held  lightly  over  the  face,  and  a  small  amount  of  nitrous 
oxid  and  oxygen  is  given,  never  allowing  the  patient  to 
become  unconscious.  This  procedure  is  usually  explained 
by  the  ward  physician  the  night  before  during  his  social 


PREOPERATIVE  MANAGEMENT  OF  EXOPHTHALMIC  GOITER   199 

call.  In  some  cases  several  mornings  are  required  to  get 
the  inhalations  started,  because  if  the  patient  becomes 
at  all  disturbed,  the  maneuver  is  suspended,  to  be  tried 
again  the  next  morning. 

On  the  morning  of  the  operation  a  hypodermic  injec- 
tion of  morphin,  gr.  |,  and  atropin,  gr.  ri^,  is  substituted 
for  the  sterile  water.  The  patient  is  not  disturbed  by 
nurses  or  visitors  after  the  hypodermic  injection  has  been 
given,  and  at  the  usual  time  the  anesthetist  gives  the  inhala- 
tion. This  time  the  patient  is  allowed  to  pass  into  the 
analgesic  or  anesthetic  stage,  and  in  this  condition  is  operated 
upon  in  his  bed,  if  the  severity  of  the  case  demands  it,  or 
is  transferred  to  the  operating  room. 


THE  ROLE  OF  THE  NURSE  IN  THE  PREOPERATIVE  AND 
POSTOPERATIVE  CARE  OF  THE  PATIENT  WITH  EX- 
OPHTHALMIC GOITER 

ABBIE  R.  PORTER 


SINCE  patients  with  exophthalmic  goiter  are  in  a  very 
abnormal  mental  state — frightened  and  apprehensive — 
the  nurse's  first  duty  is  to  gam  their  confidence,  and  to 
reassure  them  in  every  possible  way.  The  general  pre- 
operative  routine  to  which  all  patients  are  subjected  upon 
admission  to  the  hospital  must  be  applied  also  to  exophthal- 
mic goiter  patients,  but  in  such  a  way  that  it  is  scarcely 
obvious  to  them.  As  a  rule  patients  are  weighed,  measured, 
etc.,  as  soon  as  they  reach  the  hospital.  The  goiter  patient, 
however,  is  put  to  bed  at  once;  and  some  time  during  the 
first  day,  as  opportunity  presents  itself,  the  weight,  measure- 
ment, temperature,  pulse,  respiration,  and  blood-pressure, 
both  diastolic  and  systolic,  are  taken. 

As  soon  as  these  patients  have  been  seen  by  the  doctor 
they  are  placed  on  a  special  preoperative  routine,  which 
consists  chiefly  of  rest  and  quiet  in  bed.  An  ice-bag  is 
placed  over  the  heart  and  is  kept  there  constantly.  Each 
night  the  patient  is  given  a  sponge  bath  if  restless,  and 
thirty  grains  of  sodium  bromid  if  required  to  insure  a  good 
night's  rest.  The  regular  house  diet  is  given  with  especial 
restrictions — tea,  coffee,  red  meats,  highly  seasoned  and 
glandular  foods,  such  as  sweetbreads,  oysters,  etc.,  being 
eliminated. 

At  7.30  on  the  morning  of  the  second  day  after  admis- 
sion a  sponge-bath  is  given.  The  operating  clothes  are  put 

201 


202  THE   THYROID    GLAND 

on  and  a  hypodermic  injection  of  sterile  water  is  given 
between  7.30  and  8.30  A.  M.  The  hour  is  thus  varied  be- 
cause on  the  morning  of  the  day  of  operation  a  hypodermic 
injection  of  morphin  and  atropin  will  be  given  between  these 
hours,  an  hour  before  the  operation  is  to  be  performed. 
Before  the  injection  is  given  the  shades  are  drawn,  and 
afterward  the  patient  is  left  absolutely  alone.  If  any  ques- 
tions are  asked,  it  is  explained  that  the  injection  is  part  of 
the  treatment. 

The  best  rule  for  the  nurse  to  follow  during  the  first 
few  days  is  to  say  as  little  as  possible;  first,  in  order  to 
avoid  the  possibility  of  contradicting  anything  which  may 
have  been  said  at  the  doctor's  office  previous  to  the  patient's 
admission  to  the  hospital;  and,  second,  because  it  is  always 
wiser  to  study  a  patient's  temperament,  especially  that  of 
an  exophthalmic  goiter  patient,  before  talking  much. 
The  first  few  days  should,  therefore,  be  spent  in  observ- 
ing the  patient,  noting  just  where  to  break  away  from 
the  regular  routine,  just  what  to  concede. 

Seemingly  trivial  things  annoy  these  patients.  They 
are  often  greatly  annoyed  and  irritated  by  the  operating 
clothes,  and  in  such  cases  it  is  best  not  to  put  them 
on  until  the  patient  is  anesthetized.  One  attractive  and 
seemingly  tractable  young  girl  absolutely  refused  to  take 
her  inhalation.  Baffled  by  this  unexpected  action,  the 
nurse  studied  her  patient  in  order  if  possible  to  discover 
the  difficulty,  and  later  in  the  day  found  that  this  girl's 
special  pride  was  her  hair,  and  the  fact  that  it  was  not 
arranged  in  a  certain  way  so  annoyed  her  that  she  became 
quite  unreasonable.  The  next  morning  her  hair  was  be- 
comingly dressed,  and  she  took  the  inhalation  without 
resistance.  It  is  therefore  evident  that  each  case  must  be 
studied  individually  and  treated  accordingly. 


ROLE    OF    NURSE    IN    EXOPHTHALMIC    GOITER 


203 


Each  morning  between  eight  and  nine  o'clock  an  inhala- 
tion from  the  nitrous  oxid  anesthetic  apparatus  is  given 
by  the  anesthetist.  This,  like  the  hypodermic  injection,  is 
explained  as  part  of  the  treatment.  Breakfast  is  served 
between  nine  and  half-past  ten,  according  to  the  time  at 
which  the  inhalation  was  given.  The  nurse  must  watch  the 
effect  of  the  first  inhalation  carefully  in  order  to  report  any 


Fig.  60. — Operation  in  patient's  room.    Schematic  drawing  showing  arrange- 
ment of  room  and  position  of  operating  staff. 

increase  in  the  pulse-rate,  restlessness,  or  other  significant 
symptoms  to  the  resident  or  the  surgeon. 

During  the  preoperative  period  the  exophthalmic  patient 
is  sent  in  a  wheel-bed  to  the  hospital  porch  for  one  hour 
each  morning  and  afternoon.  Care  is  taken  to  keep  these 
patients  from  the  other  patients  in  order  that  they  may 
not  become  excited.  For  the  same  reason  visitors  are 
restricted  to  one  only  for  one-half  hour  twice  a  day. 


204 


THE    THYROID    GLAND 


On  the  morning  of  the  operation  the  routine  described 
above  is  followed,  but  morphin  or  atropin  are  substituted 
for  the  hypodermic  injection  of  sterile  water.  The  inhala- 


Fig.  61. — Operation  in  patient's  room.    Position  of  patient  and  arrangement 
of  aseptic  coverings. 

tion  is  given  as  on  the  previous  days,  but  a  sufficient  amount 
of  nitrous  oxid  is  added  to  the  oxygen  to  produce  analgesia. 
If  the  operation  is  to  be  performed  in  the  patient's  room 


ROLE   OF   NURSE   IN   EXOPHTHALMIC    GOITER  205 

all  the  essential  articles  are  placed  on  a  wheel-bed  or  cart 
in  the  hall  outside.  This  is  brought  into  the  room  just  as 
soon  as  the  anesthetist  indicates  the  patient  is  ready, 
as  are  also  the  sterile  trays  which  have  been  sent  from  the 
operating  room  (Figs.  60-62). 

Just  before  the  close  of  the  operation  the  patient's 
nurse  should  be  in  the  room  in  order  to  remove  everything 
which  was  not  in  the  room  before  the  operation,  and  to 


Fig.  62. — Operation  in  patient's  room.     Patient  ready  for  operation. 

have  the  shades  drawn  so  that  when  the  anesthetic  mask  is 
removed  the  room  will  appear  just  as  the  patient  remembers 
it.  An  ice  compress  is  then  placed  over  the  patient's  fore- 
head and  eyes;  she  is  propped  up  with  four  or  five  pillows, 
and  is  left  with  one  nurse.  The  postoperative  care  then 
begins. 

Sponging  of  the  hands  and  face  and  a  general  sponge 
bath  for  restlessness  are  given  as  occasion  demands.  The 
temperature,  pulse,  and  respiration  are  watched  carefully, 


206  THE    THYROID   GLAND 

the  temperature  being  taken  every  two  hours.  Any  rise 
in  temperature  is  immediately  reported  to  the  resident. 
Six  or  more  ice-packs  are  placed  around  the  patient  if  a 
temperature  of  101°  F.  or  over  is  reached.  If  the  tempera- 
ture rises  to  103°  F.  the  patient  is  put  in  an  ice-pack  as 
is  described  elsewhere  in  this  volume,  and  the  pulse  and 
respiration  are  taken  and  recorded  every  fifteen  minutes. 
Any  increase  or  irregularity  in  pulse  or  respiration  is  re- 
ported at  once.  At  all  times  an  emergency  tracheotomy 
tray  is  kept  ready  for  use,  but  not  in  the  patient's  room. 
Any  increase  in  the  amount  of  drainage  on  the  dressing  is 
noted  and  reported.  The  blood-pressure  is  taken  every 
four  hours. 

As  soon  as  water  is  tolerated,  it  is  urged.  Inhalations 
of  the  fumes  of  tincture  of  benzoin  compositus  in  boiling 
water  are  given  as  indicated,  beginning  the  night  following 
the  operation,  to  relieve  mucus  and  the  cough  which  at 
times  follow  thyroidectomy.  On  the  day  following  opera- 
tion soft  diet  is  given. 

During  the  postoperative  period  visitors  are  restricted 
as  before  operation.  The  patient  is  kept  in  bed  each  morn- 
ing until  10.30,  after  which  he  is  permitted  to  go  to  the 
solarium  on  a  wheel-bed  or  in  a  wheel-chair,  according  to 
the  progress  of  convalescence.  Between  two  and  five  o'clock 
he  remains  in  his  room,  and  he  is  required  to  retire  at  nine. 
During  convalescence  water  is  urged,  and  milk  is  given 
as  extra  nourishment,  routinely.  Just  before  dismissal 
from  the  hospital  the  patient  is  weighed  and  the  neck 
measured. 


THE  ROLE  OF  THE  OPERATING-ROOM  NURSE  IN  OPERA- 
TIONS ON  THE  THYROID  GLAND 


BLANCHE  E.  SNYDER 


THE  first  duty  of  the  operating-room  nurse  is  so  to  pre- 
pare the  operating  rooms  that  everything  will  be  in  readiness 
when  the  operative  schedule  begins.  This  means  that  in 
the  early  morning  the  room  must  be  cleaned  and  thor- 


fATiBNT 

-" 

GOITER                    /' 
SHEET                'v 
\ 

INSTRUMENT 
ItACK 

OPPRATIWG 
AREA 

^  

/^\    f  A  S~~\ 

ANAESTHETIST 


OPERATOR 


STRUMENT 
TABLE 


Fig.  63. — Schematic  drawing  showing  positions  of  operating  table,  instrument 
tables,  operator,  and  assistants  for  thyroidectomy. 

oughly  dusted;  that  the  supplies,  sufficient  to  carry  through 
the  morning's  work  without  interruption,  must  be  assembled; 
that  the  nurses'  table  and  the  instrument  table  must  be 
properly  set  up,  ready  to  be  uncovered  (Figs.  63-65). 

207 


208 


THE   THYROID   GLAND 


The  hot-water  bed  covering  the  operating  table  should 
be  filled  with  warm  water  and  covered  with  a  sheet  (Fig. 
66);  and  the  hand  straps,  knee  straps,  and  goiter  attach- 
ment put  in  place.  The  artificial  light  must  always  be  in 
readiness  within  easy  reach  (Fig.  67). 

The  trays  and  tables  which  hold  the  sterile  supplies 
for  the  operation  in  the  patient's  room  or  on  the  wards 


INSTRUMENT        TABLE 

Fig.  64. — Arrangement  of  instruments  on  instrument  table  for  thyroidec- 
tomy:  1,  1  pair  of  Crile  retractors.  2,  6  Ochsner  clamps.  3,  4  muscle  clamps. 
4,  2  mouse-tooth  dressing  forceps.  5,  Skin  clips.  6,  Skin  clips  forceps.  7, 
12  hemostats.  8,  12  hemostats.  9,  12  hemostats.  10,  12  hemostats.  11,  12 
hemostats.  12,  2  Alice  hemostats.  13,  6  tetra-clamps. 

and  in  the  operating  room  are  set  up  by  two  graduate 
"scrub-up"  nurses  with  the  assistance  of  pupil  nurses. 
As  soon  as  the  trays  are  arranged,  they  are  sent  to  the  wards. 
Operating  gowns,  clothes,  and  extra  supplies  are  also  sent 
to  the  wards  at  this  time.  This  makes  it  possible  to  carry 
through  the  entire  operative  schedule  on  the  wards  without 
returning  to  the  operating  room. 


OPEKATING-ROOM   NURSE   IN   OPERATIONS   ON   THYROID       209 


— "^        \  I 

,z    _  U        is        V  / 

\          \  z.o         2i  ^ 17  ' 


Fig.  65. — Arrangement  of  instruments  and  supplies  on  nurses'  table  for 
thyroidectomy :  1,  4  gauze  dressings.  2,  Plain  sheet.  3,  2  tetra  cloths.  4, 
Goiter  mask.  5,  4  towels.  6,  36  gauze  sponges.  7,  2  table  covers.  8,  Crile 
needle-holders.  9,  Parker  detachable-blade  knives.  10,  Luer  syringes  for 
novocain  injection.  11,  Kelly  forceps  with  cotton  pledgets  for  scrubbing 
field  of  operation.  12,  Nurses'  scissors.  13,  Straight  shears.  14,  Kelly  oblique 
needles  No.  2.  15,  Table  pad  folded  into  9-inch  square  for  threaded  sutures. 
16,  Solution  basin  for  sutures.  17,  Specimen  basin.  18,  Suture  material  basin 
containing  reel  of  black  silk,  flexible  rubber  drain,  5  tubes  Luken's  plain  cat- 
gut No.  1.  19,  Curved  basin  for  catgut  tubes.  20,  Novocain  1  :  200  solution. 
21,  Picric  acid  5  per  cent,  in  alcohol. 


Fig.  66. — Hot-water  mattress  on  operating  table. 


In  thyroid  operations  in  which  the  anesthetic  is  started 
in  the  patient's  room  the  operating  nurse  must  have  an 
operating  room  wheeled  stretcher  waiting  outside  the 

14 


210 


THE   THYROID    GLAND 


* 


patient's  room,  so  that  the  patient  may  be  taken  to  the 
operating  room  as  soon  as  the  anesthetist 
has  him  ready.  The  ward  surgeon  must 
previously  have  been  notified,  so  that  he 
will  be  on  the  ward  ready  to  accompany 
his  patient  to  the  operating  pavilion,  for 
patients  to  whom  the  anesthetic  is  admin- 
istered in  their  rooms  are  always  accom- 
panied to  and  from  the  operating  room  by 
the  ward  surgeon. 

When  the  patient  arrives  in  the  oper- 
ating room  and  has  been  transferred  to 
the  operating  table  the  nurse  must  at 
once  see  that  the  goiter  attachment  is  in 
the  proper  position,  that  is,  a  3-inch  ele- 
vation should  be  under  the  patient's 
shoulders.  The  gown  and  flannel  jacket 
are  then  turned  down  and  the  hand  and 
knee  straps  tied,  after  which  the  nurse  is 
ready  to  "pour  scrubs" — ether  and  a  5 
per  cent,  solution  of  picric  acid  in  alcohol. 
The  most  important  part  played  by  the 
operating-room  nurse  begins  at  this  time. 
She  must  watch  the  "scrub-up  nurse" 
very  carefully,  keeping  her  table  well  sup- 
plied with  novocain,  sponges,  catgut,  etc., 
so  as  to  eliminate  delay  during  the  opera- 
tion— a  sufficient  supply  of  these  articles 
is  always  placed  in  the  operating  room 
early  in  the  morning.  The  operating- 
room  nurse  is  also  responsible  for  having 
tracheotomy  tubes  sterilized  and  at  hand,  so  that,  in  emer- 
gency, they  may  be  given  to  the  "instrument  man"  (surgical 


a 

1 

w 


o 

bb 

£ 


OPERATING-ROOM   NURSE    IN    OPERATIONS    ON   THYROID       211 

intern)  without  any  delay  whatsoever.  It  is  hard  to  make 
the  pupil  nurses  understand  the  necessity  for  this,  as  a 
tracheotomy  is  so  rarely  required.  The  nurse  must  also 
watch  the  instrument  table  carefully,  adding  more  instru- 
ments, particularly  hemostats,  as  the  operation  progresses. 
The  number  of  hemostats  used  varies  considerably  in  differ- 
ent thyroid  operations,  the  average  number  being  about  six 
dozen. 

As  the  extent  of  the  operation  will  depend  entirely  upon 
the  condition  of  the  patient,  and  as,  therefore,  the  patient 
may  be  sent  back  to  his  bed  at  any  moment — after  the 
excision  of  one  or  of  both  lobes — with  the  wound  dressed 
open  with  flavin  gauze,  the  nurse  must  always  be  ready 
with  her  dressings. 

After  one  patient  leaves  the  operating  room  the  nurse 
in  charge  must  be  prompt  in  preparing  the  room  for  the 
following  operation  so  that  there  may  be  no  delay  in  getting 
it  started.  This  is  particularly  important  in  cases  in  which 
the  patient  comes  to  the  operating  room  under  anesthesia, 
as  every  minute's  delay  means  an  unnecessary  prolongation 
of  the  anesthesia.  It  is  almost  equally  important,  how- 
ever, when  the  patient  is  brought  to  the  operating  room 
without  being  anesthetized,  for  it  is  then  essential  that  the 
anesthetic  be  started  at  once  before  the  patient  has  time 
to  become  unnecessarily  excited  by  viewing  the  operating 
room. 

When  the  thyroidectomy  is  to  be  performed  in  the 
patient's  room  the  co-operation  of  the  ward  nurses  is  essen- 
tial, and  is  always  gladly  given.  They  prepare  and  have 
waiting  outside  the  patient's  room  the  drop  light,  ether, 
picric  acid  solution,  alcohol,  ice  compresses,  and  small 
bedside  tables  on  which  the  sterile  dressings  are  placed. 
Thus  but  a  moment  is  required  for  these  articles  to  be 


212  THE   THYROID    GLAND 

taken  inside  the  patient's  room  after  the  anesthetic  is 
started. 

The  operating-room  orderlies  follow  up  all  operations 
on  the  ward,  and  return  the  trays  to  the  operating  room 
promptly  after  each  operation.  In  this  way,  by  the  time 
that  the  ward  work  has  been  completed,  all  operating- 
room  supplies  have  been  returned  and  have  been  washed 
and  resterilized  by  pupil  nurses,  so  that  when  the  doctors 
and  nurses  return  to  the  operating  room  after  having  per- 
formed from  four  to  eight  operations  in  the  patients'  rooms 
everything  is  in  readiness  to  continue  the  morning's  work 
in  the  operating  room  itself. 

The  graduate  "scrub-up  nurses"  play  a  very  important 
part  in  connection  with  thyroidectomies,  as  they  are  ex- 
pected not  only  to  anticipate  the  wishes  of  the  operator 
but  also  those  of  his  assistants.  In  this  clinic  a  spirit  of 
entire  co-operation  has  been  developed  among  the  surgeon, 
the  assistants,  and  the  "scrub-up  nurses."  This  co-operation 
is  of  vital  importance  to  the  operating-room  nurse,  whose 
prime  duty  it  is  to  assist  in  every  way  possible  in  shortening 
the  duration  of  the  operation,  particularly  in  extremely 
severe  cases  of  exophthalmic  goiter  when  the  operation 
is  performed  without  moving  the  patient  from  bed. 


THE  ADMINISTRATION  OF  NITROUS  OXID-OXYGEN 
ANALGESIA  IN  OPERATIONS  ON  THE  THYROID 
GLAND 

AGATHA  HODGINS 


FOR  all  goiter  operations  nitrous  oxid-oxygen  analgesia 
is  the  anesthetic  method  of  choice,  whatever  the  physical 
condition  of  the  patient.  The  more  serious  the  risk,  the 
greater  is  the  necessity  for  using  analgesia. 

PLAIN  GOITERS 

For  the  removal  of  the  usual  colloid  goiter,  if  the  patient's 
general  condition  is  good,  and  there  is  no  reason  for  modify- 
ing the  routine  surgical  procedure,  the  patient  is  brought 
to  the  operating  room  and  the  anesthetic  is  administered 
there  in  the  usual  way.  In  these  cases,  especially  if  the 
gland  is  large,  the  anesthetist  must  bear  in  mind  the  possi- 
bility of  compression  or  collapse  of  the  trachea,  with  conse- 
quent interference  with  the  respiratory  exchange.  Should 
this  happen,  the  immediate  administration  of  oxygen 
under  pressure  will  overcome  the  condition. 

Since  the  dissection  may  be  difficult  the  anesthetist 
must  make  sure  that  the  air  passages  are  clear.  If  there 
is  any  tendency  to  obstruction  the  flat  air-way  is  inserted. 
This  appliance  in  no  way  affects  the  condition  of  the  patient, 
while  it  does  assure  the  anesthetist  that  no  obstruction 
can  occur  as  a  result  of  the  tongue's  dropping  back  over 
the  pharynx.  With  this  precaution,  if  obstruction  does 
occur,  it  will  be  below  the  larynx,  in  which  case,  unless  the 
obstruction  is  complete,  the  anesthetist  can  keep  the  patient 
safe  with  oxygen  given  under  pressure. 

213 


214  THE   THYROID   GLAND 

Nasal  tubes  are  useful  in  these  cases,  but  as  their  intro- 
duction necessitates  deepening  the  anesthetic  while  the 
tubes  are  inserted,  it  has  been  our  experience  that  this 
procedure  is  usually  unwise.  However,  when  the  tubes 
are  inserted,  a  very  smooth,  even  type  of  respiration  is 
insured.  With  the  mouth  closed,  the  lungs  can  be  very 
quickly  insufflated  with  oxygen  through  the  upper  air 
passages.  A  valve  for  regulating  the  pressure  is,  of  course, 
attached  to  the  gas  machine.  The  ease  with  which  nitrous 
oxid-oxygen  anesthesia  can  be  deepened  or  diminished  also 
contributes  to  the  comfort  and  safety  of  the  patient.  Some 
patients  are  carried  to  full  surgical  anesthesia  during  a 
difficult  part  of  the  operation,  after  which  they  are  brought 
back  to  analgesia. 

EXOPHTHALMIC  GOITER 

For  operations  on  exophthalmic  goiter  patients  we  employ 
a  different  technic.  These  patients  are  hypersensitive  to 
any  external  stimuli,  their  sense  of  fear  is  exaggerated, 
and  they  make  a  marked  response  to  even  slight  physical 
injury.  These  patients,  therefore,  must  be  approached 
with  great  caution.  On  several  consecutive  days  before 
the  day  of  operation  they  are  given  inhalations  of  oxygen, 
with  perhaps  a  very  small  amount  of  nitrous  oxid,  in  order 
that  the  preoperative  apprehension  of  the  patient  may  be 
minimized.  This  procedure  is  also  valuable  to  the  anes- 
thetist, as  it  gives  her  a  very  good  idea  of  the  patient's 
reaction  to  the  anesthetic;  in  other  words,  she  gets  an 
idea  of  the  patient's  mental  control.  It  is  necessary  that 
these  patients  be  handled  both  tactfully  and  sympathetically 
by  the  anesthetist.  For  this  reason  it  is  very  important 
that  an  anesthetist  be  taught  the  proper  method  of  approach 
to  a  patient.  The  preoperative  inhalations  are  made  to 


NITROUS   OXID-OXYGEN   IN   OPERATIONS   ON   THYROID      215 

appear  as  very  ordinary  procedures.  No  mention  is  made 
of  going  to  sleep  or  of  anesthesia.  The  anesthetist  usually 
speaks  casually  about  giving  the  patient  a  little  oxygen 
to  see  how  he  will  adjust  himself  to  breathing  into  the 
face  mask,  assuring  him  that  it  will  be  a  very  comfortable 
and  easy  thing  to  do.  On  the  morning  of  the  ligation  the 
anesthetist  enters  the  patient's  room  in  the  usual  way 
to  give  the  inhalation.  This  time,  however,  the  patient 
is  told  that  the  doctor  is  coming  in  to  look  at  his  neck  and 
that  he  will  perhaps  put  some  medicine  on  the  skin. 

The  state  of  analgesia  is  then  approached,  and  the 
mental  control  of  the  patient  is  assured  by  the  anesthetist. 
The  anesthetist  follows  the  line  of  least  resistance  with 
these  patients  and  tries  to  secure  their  co-operation  by 
means  of  suggestion  rather  than  command.  Fortunately, 
in  most  patients  analgesia  establishes  more  or  less  indiffer- 
ence to  the  environment,  a  condition  to  the  advantage  of 
the  anesthetist  in  securing  mental  control  of  the  patient. 
As  the  preparation  of  the  patient  for  operation  proceeds 
everything  that  is  done  is  explained  in  a  matter-of-fact 
manner.  We  have  found  that,  unless  there  is  an  utter 
lack  of  self-control,  patients  respond  very  well  indeed  to 
the  suggestion  that  they  can  co-operate  with  the  anesthetist. 

The  pressure  sense  is  exaggerated  under  analgesia. 
Therefore  when  there  is  any  evidence  that  the  face  mask 
is  causing  discomfort  it  is  taken  off  and  the  gas  is  allowed 
to  flow  over  the  patient's  face  without  actual  contact. 
Cloths  chilled  with  ice  should  be  at  hand,  as  they  are  very 
refreshing  when  placed  over  the  eyes  and  forehead. 

It  must  be  remembered  in  connection  with  the  adminis- 
tration of  analgesia  that  it  is  necessary  for  the  anesthetist 
to  interpret  the  respiration  of  the  patient  and  the  expres- 
sion of  his  eyes  in  order  to  judge  accurately  the  exact  stage 


216  THE   THYROID   GLAND 

of  analgesia  at  any  moment.  It  has  been  our  experience 
that  for  the  first  five  minutes  patients  vary  to  about  the 
same  degree  as  during  the  induction  of  anesthesia.  The 
first  subjective  feeling  which  the  patient  experiences  is 
usually  one  of  warmth  and  exhilaration.  During  this 
stage  the  respiratory  rate  may  be  a  little  increased,  and 
the  anesthetist  needs  to  instruct  the  patient  to  breathe 
more  slowly,  to  relax  his  muscles,  and  to  take  things  quietly. 

After  this  phase  the  secondary  stage  of  analgesia  de- 
velops. In  this  stage  the  indifference  to  surroundings 
becomes  more  or  less  apparent.  A  "don't  care"  state  of 
mind  is  evidenced.  The  respiratory  rate  is  slow,  some- 
times slower  than  normal,  partly  due,  perhaps,  to  the  pre- 
anesthetic  dose  of  morphin.  The  expression  of  the  eyes 
supplies  a  valuable  guide.  There  is  usually  a  quiet,  sleepy 
expression  and  the  movement  of  the  eyeball  itself  is  very 
slow.  The  anesthetist,  however,  should  be  able  to  main- 
tain direct  contact  with  the  patient,  asking  him  to  open 
his  eyes  and  to  look  at  her.  Sometimes  the  patient  is  dis- 
inclined to  do  this,  and  insisting  upon  this  point  may  pro- 
duce discomfort  and  fretfulness.  The  face  assumes  the 
tranquillity  of  sleep.  As  the  stage  of  analgesia  proceeds, 
after  ten  minutes,  huskiness  of  the  voice  may  become 
apparent.  In  some  patients  slow  response  and  inco-ordina- 
tion  of  thought  is  marked.  The  pressure  sense  is  exagger- 
ated, so  that  the  patient  may  complain  of  pressure  during 
the  operation.  The  respiratory  and  pulse-rates  are  usually 
unchanged.  However,  in  a  very  apprehensive  patient, 
there  may  be  an  increase  in  the  pulse  and  respiratory  rate 
when  pressure  is  being  exerted  by  the  surgeon  or  when 
pain  is  felt. 

It  must  be  remembered  that  the  next  anesthetic  stage 
after  that  of  indifference  is  that  of  intoxication,  which  is 


NITROUS   OXID-OXYGEN   IN   OPERATIONS   ON   THYROID      217 

always  marked  by  an  increase  in  the  rate  of  respiration; 
the  tranquil  expression  of  the  eyes  vanishes  and  they  assume 
an  active  expression.  At  this  stage  it  is  difficult  for  the 
anesthetist  to  be  guided  in  gaining  mental  control  of  the 
patient  by  looking  at  his  eyes. 

When  a  marked  exhilaration  is  manifested  at  the  begin- 
ning of  analgesia  the  anesthetist  must  bear  in  mind  that 
such  patients  very  rapidly  approach  the  stage  of  intoxica- 
tion, which  may  interfere  with  control.  These  patients 
are  also  very  near  the  dream  stage.  If  the  hallucinations 
or  sensations  are  unpleasant,  the  patient  shows  evidence 
of  mental  stress.  It  is  nearly  always  a  simple  matter  to 
bring  the  patient  back  to  the  stage  of  indifference  by  say- 
ing that  the  anesthetist  wants  him  to  talk  to  her.  By 
watching  the  rate  of  respiratory  decrease  and  the  return 
of  the  eyes  to  an  expression  of  tranquillity,  it  is  possible 
again  to  approach  the  true  analgesic  state. 

Patients  who  by  reason  of  the  severity  of  their  illness 
are  apprehensive  sometimes  have  the  impression  that  the 
duration  of  time  is  much  prolonged.  If  at  any  time  during 
the  analgesia  the  patient  should  drift  into  oblivion,  his 
sense  of  the  duration  of  time  is,  of  course,  immediately 
shortened.  It  must  also  be  borne  in  mind  that  with  the 
perfect  nerve-blocking  of  local  anesthesia  this  drifting 
into  light  sleep  may  occur.  When  this  happens  it  is  a  per- 
fect state  for  the  patient.  The  pulse-rate  is  normal,  the 
color  is  good,  the  respiration  is  tranquil,  and  the  patient 
is  apparently  undisturbed  mentally.  Dreams,  if  they 
occur,  are  usually  of  a  pleasant  or  interesting  nature. 

The  anesthetist  must,  of  course,  realize  that  it  devolves 
upon  her  to  guide  the  patient  through  the  analgesic  stage 
and  to  interpret  to  him  comfortably  the  happenings  of  the 
operation.  This,  of  course,  requires  study  and  an  adapta- 


218  THE   THYROID   GLAND 

bility  which  is  not  always  easily  attained.  It  is  also  neces- 
sary that  there  be  perfect  co-operation  between  the  surgeon 
and  his  anesthetist.  At  the  end  of  the  operation  the  anes- 
thetist explains  to  the  patient  that  she  wants  him  to  have 
a  sleep.  She  also  impresses  on  him  how  much  his  co-opera- 
tion has  been  appreciated  and  in  what  a  splendid  condition 
he  is. 

SPECIAL  NOTES 

At  the  present  time  most  of  our  severe  exophthalmic 
goiter  cases  are  operated  upon  in  the  patient's  room  under 
analgesia  plus  local  anesthesia.  During  the  course  of  a 
thyroidectomy  the  perfect  blocking  with  local  anesthesia 
is  a  more  necessary  factor  in  the  maintenance  of  good 
analgesia  than  is  the  case  with  ligation.  It  may  develop 
that  the  enucleation  of  the  gland  is  a  more  difficult  pro- 
cedure than  the  surgeon  had  anticipated.  If  this  happens, 
the  anesthetist  should  be  warned  by  the  surgeon.  However, 
she  will  know  by  the  increased  activity  of  the  respiration, 
pained  expression  of  the  face,  increase  in  the  pulse-rate, 
and  the  activity  of  the  eyes  that  the  patient  is  not  com- 
fortable. If  the  situation  is  not  promptly  met  by  the 
surgeon  it  may  be  necessary  for  the  anesthetist  to  explain 
to  the  patient  that  she  knows  he  is  not  comfortable,  and 
that  she  is  going  to  let  him  have  a  little  sleep  for  a  few 
minutes.  The  increased  activity  of  the  respiration,  which 
results  from  breaking  through  the  veneer  of  analgesia, 
will  make  it  necessary  for  the  anesthetist  to  increase  the 
dosage  of  nitrous  oxid  in  order  to  control  the  phenomena 
thus  developed.  As  soon  as  comfort  is  re-established  the 
rate  of  respiration  becomes  slower,  the  eyes  again  become 
tranquil,  and  the  troubled  expression  of  the  face  disappears. 
The  anesthetist  must  then  bring  the  patient  back  quickly 
to  analgesia,  as  otherwise  the  patient  will  drift  over  into 


NITROUS   OXID-OXYGEN   IN   OPERATIONS   ON   THYROID      219 

the  second  or  dream  stage  of  anesthesia,  which  is  the  most 
uncomfortable  state  for  the  patient  and  the  most  difficult 
for  the  anesthetist  to  control.  In  some  patients  the  invasion 
of  pain  will  cause  a  temporary  feeling  of  faintness.  With 
these  patients  the  anesthetist  simply  says  that  she  will 
give  something  to  relieve  the  faint  feeling,  a  statement 
which  she  can  make  with  assurance,  since  we  have  found 
that  an  increased  amount  of  oxygen  will  usually  meet  the 
situation.  A  feeling  of  faintness  may  develop  also  if  the 
operation  is  prolonged.  The  application  of  cold  cloths 
to  the  lips  and  eyes  with  the  inhalation  of  oxygen  gives 
relief.  Sometimes  smelling  salts  also  are  helpful. 

One  of  the  outstanding  thoughts  in  the  anesthetist's 
mind  in  taking  a  patient  through  a  thyroidectomy  under 
analgesia  is  the  possibility  that  obstruction  of  the  trachea 
may  occur.  It  is  well,  therefore,  to  be  prepared  to  give 
the  patient  oxygen  under  positive  pressure,  should  such 
an  emergency  develop.  If  the  oxygen  brings  the  patient 
back  to  light  analgesia,  unless  the  return  to  this  stage  is 
comfortable  to  the  patient,  he  is  "put  to  sleep"  for  a  few 
minutes  to  relieve  the  distress  which  the  work  on  the 
trachea  may  have  occasioned.  After  this  phase  of  the  opera- 
tion is  passed  the  patient  is  brought  back  slowly  to  analgesia, 
and  it  is  necessary  for  the  anesthetist  to  control  the  patient 
mentally  as  he  comes  back  from  oblivion  to  the  stage  of 
indifference.  In  other  words,  as  soon  as  the  respiratory 
phenomena  and  the  expression  of  the  face  indicate  that 
the  patient  is  coming  back  to  analgesia,  the  anesthetist 
must  again  control  him  by  suggestion. 

It  is  of  the  utmost  importance,  of  course,  that  any 
untoward  or  serious  occurrence  during  an  operation  under 
analgesia  be  kept  from  the  patient's  knowledge.  There 
should  be  no  whispering  during  an  operation,  as  whispering 


220  THE   THYROID   GLAND 

always  arouses  suspicion  and  anxiety  on  the  part  of  the 
patient.  Unnecessary  noise  and  the  clinking  of  instru- 
ments must  be  avoided.  The  exaggeration  of  the  sense 
of  sound  under  analgesia  is  very  marked  in  some  patients. 
Others  are  apparently  indifferent  to  sounds.  If  the  surgical 
procedures  should  involve  injury  or  pressure  on  the  laryngeal 
nerve  there  will  result  stertor  and  disturbance  of  respira- 
tion with  attendant  restlessness.  Therefore,  unless  the 
patient  is  an  unusually  good  subject  for  analgesia  and  the 
anesthetist  has  established  perfect  control  from  the  begin- 
ning, it  is  advisable  to  put  the  patient  into  the  stage  of 
light  anesthesia.  Deep  anesthesia  should  be  avoided. 

In  milder  cases  of  exophthalmic  goiter,  when  it  is  felt 
that  it  is  not  necessary  to  perform  the  operation  in  the 
patient's  room,  the  patient  is  anesthetized  in  bed,  lifted 
from  the  bed  to  the  wheeled  stretcher,  and  taken  to  the 
operating  room  under  light  anesthesia.  When  the  patient 
has  been  placed  comfortably  on  the  operating  table  he  is, 
if  possible,  brought  back  to  the  stage  of  analgesia.  When 
the  patient  does  not  come  back  to  the  stage  of  analgesia 
with  comfort,  light  anesthesia  is  maintained  throughout 
the  operation.  Toward  the  end  of  the  operation  the  anes- 
thesia is  moderated  to  analgesia,  the  patient  is  lifted  from 
the  operating  table  to  the  stretcher,  taken  back  to  the 
ward  under  very  light  analgesia,  and  put  comfortably  in 
his  bed.  These  patients  have  no  memory  of  proceedings 
before  and  for  some  tune  after  the  point  of  oblivion  is 
reached. 

In  cases  of  adenomata  in  which  there  is  no  cardiac 
impairment  or  other  special  necessity  for  the  protection 
of  the  patient,  the  patient  is  taken  to  the  operating  room 
and  put  under  analgesia  there.  This  necessitates  a  quick 
grasp  of  the  situation  by  the  anesthetist.  It  is  somewhat 


NITROUS   OXID-OXYGEN   IN   OPERATIONS   ON   THYROID      221 

harder  to  get  the  mental  control  of  the  patient  in  the  operat- 
ing room  than  it  is  in  the  patient's  bedroom.  As  every- 
thing around  the  patient  indicates  operative  procedure, 
the  anesthetist  has  a  more  difficult  task. 

In  some  patients  the  respiration  is  hyperactivated. 
This  activation  of  the  respiration  makes  it  rather  difficult 
to  establish  true  analgesia.  If  there  is  considerable  hyper- 
activation,  both  mental  and  respiratory,  it  is  sometimes 
best  to  put  the  patient  under  anesthesia  and  then  bring 
him  back  slowly  to  analgesia.  This  is  usually  a  more  effec- 
tive procedure  than  to  try  to  exert  mental  control  over  a 
patient  who  is  already  hyperactive,  but  whose  condition 
is  not  endangered  by  anesthesia.  Usually  these  patients 
tolerate  the  operative  procedure  very  well,  and  it  is  simply 
a  question  of  carrying  them  through  the  operation  with 
mental  comfort  and  without  tiring  the  respiration. 

In  anesthesia  in  contrast  with  analgesia  it  must  be 
remembered  that  in  these  patients  as  well  as  with  exoph- 
thalmic goiter  patients  nausea  may  develop,  and  there- 
fore, whenever  possible,  it  is  best  to  avoid  deep  anesthesia. 
Light  anesthesia  is  better  and  analgesia  is  best.  With 
true  analgesia  there  is  no  nausea.  It  is  only  when  a  patient 
approaches  the  second  or  intoxication  stage  or  has  passed 
well  into  that  stage  that  nausea  occurs,  for  our  experience 
with  nitrous  oxid-oxygen  anesthesia  seems  to  indicate 
that  nausea  is  in  part  at  least  the  result  of  suboxidation. 
Other  factors  which  may  produce  nausea  are  fear  and  the 
preliminary  dose  of  morphin.  The  sign  of  approaching 
nausea  is  usually  an  indication  for  oxygen. 

The  hyperactivity  shown  at  the  beginning  of  the  anes- 
thesia may  be  repeated  at  the  end  of  the  operation.  If 
this  is  marked,  the  patient  is  treated  as  in  exophthalmic 
goiter  and  is  taken  back  to  his  room  under  light  analgesia. 


222  THE    THYROID   GLAND 

This  is  done  also  when  there  has  been  a  mechanical  obstruc- 
tion of  the  trachea  with  the  consequent  necessity  for  pure 
oxygen  after  the  operation. 

SUMMARY 

1.  The  proper  administration  of  analgesia  requires  pro- 
longed special  training  on  the  part  of  the  anesthetist. 

2.  Analgesia  therefore  offers  the  greatest  measure   of 
protection  to  the  patient. 

3.  The  surgeon  and  anesthetist  must  co-operate  closely. 

4.  All  forms  of  inhalation  anesthesia  interfere  with  the 
internal  respiration.     In  exophthalmic  goiter  the  internal 
respiration  is  near  the  point  of  failure.    Analgesia  does  not 
interfere  with  the  internal  respiration. 


THE    TECHNIC    OF    OPERATIONS    ON    THE    THYROID 

GLAND* 

G.  W.  CRILE  AND  W.  E.  LOWER 


THE  TYPICAL  LIGATION 

ALL  ligations  are  performed  under  analgesia  and  local 
anesthesia  in  the  patient's  room  without  removing  the 
patient  from  his  bed.  The  superior  thyroid  artery  is  ligated 


Fig.  68. — Ligation  of  superior  thyroid  artery.    Infiltration  of  skin. 


in  preference  to  the  inferior  artery  for  the  reason  that  the 
latter  lies  deeper  and  its  ligation  apparently  is  less  effective, 
probably  because  the  nerve  supply  to  the  thyroid  runs 
along  the  wall  of  the  superior  artery.  The  field,  including 
the  skin,  subcutaneous  tissue,  muscles,  etc.,  is  completely 

*  Reprinted  from  Surg.,  Gym,  and  Obst.,  1922,  xxxiv,  258-264. 

223 


224 


THE    THYROID   GLAND 


infiltratea  with   1  : 200  novocain   (Figs.   68,  69).     Imme- 
diately after  the  novocain  is  injected  firm  pressure  is  made 


Fig.  69. — Ligation  of  superior  thyroid  artery.    Deep  infiltration  for  complete 
protection  of  field  of  operation. 

over  the  injected  area,  as  this  diffuses  the  anesthetic  and 
increases  its  efficiency.    The_skin  isdivided  parallel  to  the 


Fig.  70. — Ligation  of  superior  thyroid  artery.    Line  of  incision  through  fascia. 

skin  folds,  and  should  be  symmetrical  on  the  two  sides,  if 
both  sides  are  ligated.     The  fascia  is  then  divided,  exposing 


TECHNIC    OF   OPERATIONS   ON   THYROID   GLAND 


225 


the  preglandular  muscles  (Fig.  70).     The  muscle^  are  not 
severed,  but  the  fibers  are  separated  with  narrow-bladed 


Fig.  71. — Ligation  of  superior  thyroid  artery.     Separation  of  fibers  of  pre- 
glandular muscles  with  narrow-bladed  hemostats. 


Fig.  72. — Ligation  of  superior  thyroid  artery.     Passage  of  suture  under  artery 
which  is  elevated  with  forceps. 

hemostatic  forceps  (Fig.  71)  and  the  divided  muscles  are 
held  apart  to  expose  the  upper  pole  of  the  gland  by  means 
of  special  retractors  having  different  sized  blades.  This 

15 


226 


THE   THYROID   GLAND 


INFILTRATION. 
SUBCUTANEOUS     Tissue 


Fig.  73. — Ligation  of  superior  thyroid  artery:  A,  Sutures  of  artery  and 
of  superior  pole.  B,  Infiltration  of  pole  and  of  subcutaneous  tissues  with 
quinin  and  urea  hydrochlorid. 


Fig.  74. — Ligation  of  superior  thyroid  artery.    Closure  of  skin  incision  with 

clips. 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND 


227 


retraction  gives  an  almost  uniform  exposure  of  the  artery, 
which  is  then  picked  up  and  held  by  a  forceps  while  a  full 
curved  needle  armed  with  silk  is  carried  around  it  (Fig.  72). 


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Fig.  75. — Typical  charts  showing  that  reaction  to  ligation  is  no  greater  than 
reaction  to  entrance  to  hospital. 

A  second  ligature  is  passed  around  the  superior  pole  to 
make  sure  that  the  main  artery  and  not  only  a  branch  is 
included  (Fig.  73,  A). 


228  THE   THYROID   GLAND 

The  tissue  involved  in  the  ligature  is  infiltrated  by  injec- 
tion with  1  :  600  quinin  and  urea  hydrochlorid  (Fig.  73,  B), 
as  are  the  subcutaneous  margins  which  are  to  be  grasped 
in  the  barbs  of  the  skin  clips,  the  injection  being  made  from 
below  outward  so  that  the  skin  border  becomes  white  and 
edematous.  No  deep  sutures  are  used.  The  skin  incision 
is  closed  with  clips  (Fig.  74)  which  are  removed  on  the 
third  day,  for,  if  left  longer,  they  may  cause  slight  punc- 
tated scars. 

Usually  the  artery  of  but  one  side  is  tied  at  one  seance, 
for,  if  it  is  a  grave  risk,  the  double  ligature  would  increase 
the  hazard  too  much;  and  even  in  apparently  safe  cases 
the  single  ligation  may  disclose  a  hazardous  situation. 
Moreover,  if  there  is  doubt  as  to  whether  the  patient  might 
safely  endure  a  thyroidectomy,  a  single  ligation  will  give 
the  cue;  and  if  the  indication  is  favorable  the  thyroidectomy 
may  follow  the  tell-tale  ligation  in  three  days.  Our  rule 
is:  If  there  is  any  doubt  as  to  the  advisability  of  the  thy- 
roidectomy, make  a  single  ligation.  There  will  be  at  most 
only  a  three  days'  loss  of  tune;  and  occasionally  the  single 
ligation  may  mean  the  saving  of  a  life  (Fig.  75). 

THE  TYPICAL  RESECTION  OF  THE  THYROID  GLAND 

Posture. — The  patient  is  placed  on  the  table  in  an 
inclined  position,  feet  downward,  and  the  base  of  the  neck 
is  sufficiently  elevated  by  a  small  pillow  to  produce  an 
advantageous  elevation  of  the  chin  (Fig.  76). 

Position  of  the  Scar — the  Platysma. — A  collar  incision, 
at  about  the  level  of  the  middle  and  lower  thirds  of  the 
neck,  paralleling  the  natural  folds  of  the  skin,  is  the  favored 
position  for  the  scar.  If  the  goiter  is  large,  especially  if  the 
patient  has  a  short  fat  neck,  the  incision  must  be  made 
correspondingly  high  above  the  clavicle,  as  otherwise  the 


TECHNIC   OF   OPERATIONS   ON   THYROID   GLAND          229 


scar  will  fall  down  upon  the  sternum,  well  below  the  clavicle, 
and  be  conspicuously  displayed. 


Fig.  76. — Typical  thyroidectomy.    Position  of  patient  on  operating-table. 


! 


r 


Fig.  77. — Operator  and  assistants  ready  to  operate  on  patient  who  is  being 
brought  to  stage  of  analgesia. 

The   skin   and   subcutaneous   tissue   along  the  line   of 
incision  is  infiltrated  with  1  : 200  novocain  (Fig.  78),  after 


230 


THE   THYROID   GLAND 


which  the  incision  is  made  without  holding  the  skin,  by 
a  free  but  not  rapid  sweep  of  the  knife,  keeping  the  eyes 


Fig.  78.— 'Typical  thyroidectomy.    Distribution  of  novocain  after  infiltration 

by  pressure. 

on  a  natural  fold,  or  failing  that,  upon  the  line  of  junction 
of  the  neck  and  chest  (Fig.  79).    The  most  common  error 


Fig.  79. — Typical  thyroidectomy.     Line  of  incision  through  area  infiltrated 

with  novocain. 

is  to  make  the  incision  too  low,  especially  if  the  goiter  pro- 
trudes prominently  in  the  front  of  the  neck.     The  short- 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND 


231 


coming  of  the  so-called  necklace  incision  is  that  an  ordinary 
ribbon  or  band  will  not  cover  it  as  in  the  case  of  the  higher 
incision.  In  addition,  if  the  incision  is  made  in  the  manner 
just  described,  a  covering  will  rarely  be  required.  Under 


Fig.  80. — Typical  thyroidectomy.     Division  and  reflection  of  skin. 

no  circumstances  should  the  incision  be  made  in  a  vertical 
direction. 

The  platysma  muscle  is  divided  and  reflected  with  the 
skin  (Fig.  80).  Formerly,  in  perhaps  1000  cases,  we  made 
a  separate  dissection  and  suture  of  the  platysma,  but 
further  experience  showed  that  this  is  unnecessary,  for  if 
the  platysma  is  attached  to  the  skin,  it  will  be  approxi- 


232 


THE    THYROID   GLAND 


mated  with  the  skin  if  clips  are  used,  and  if  the  platysma 
remains  with  the  preglandular  muscles  it  will  be  approxi- 
mated with  them.  In  either  case  it  will  function  normally. 
In  other  words,  no  special  attention  is  paid  to  it. 

Preglandular  Muscles. — Shall  the  preglandular  muscles 
be  split  vertically  and  their  margins  drawn  back  by  re- 
tractors, or  shall  the  preglandular  muscles  be  divided  trans- 
versely, thus  completely  exposing  the  thyroid,  giving  the 


Fig.  81 . — Typical  thyroidectomy.    Infiltration  of  preglandular  muscles  before 

transverse  incision. 

opportunity  of  making  the  operation  of  resection  under  the 
eye  without  the  need  of  retractors  to  pull  back  the  muscles? 
In  the  case  of  small  goiters  the  median  vertical  division 
will  answer;  but  in  the  great  majority  we  have  found  it 
best  to  divide  the  muscles  transversely.  The  transversely 
divided  muscles  become  so  soundly  healed  that  no  later 
disability  occurs.  The  preglandular  muscles,  on  one  or 
both  sides  as  required,  are  therefore  divided  between  trans- 
versely applied  special  clamps  after  the  line  of  incision  and 


TECHNIC    OF   OPERATIONS   ON   THYROID    GLAND          233 


Fig.  82. — Typical  thyroidectomy.     Vertical  incision  along  infiltrated  line  in 
preglandular  muscles.     Skin-flaps  protected  by  sterile  cloths. 


Fig.  83. — Typical  thyroidectomy.     Vertical  division  of  preglandular  muscles 

exposing  gland. 

the  areas  to  be  grasped  in  the  clamps  have  been  completely 
infiltrated  with  novocain.  These  muscle  clamps  are  espe- 
cially designed  for  this  purpose.  They  grasp  and  hold, 
but  do  not  crush  the  muscle  (Figs.  81-84). 


234 


THE    THYROID   GLAND 


The  advantages  of  the  muscle  clamps  are  of  the  first 
order,  for  they  completely  control  bleeding,  their  handles 
serve  as  retractors,  and  they  cause  almost  no  tissue  injury. 
By  means  of  the  four  muscle  clamps  holding  the  divided 
muscles  the  structures  overlying  the  goiter  are  unfolded. 
After  the  neck  has  been  opened  the  skin  and  platysma 
myoides  are  protected  by  a  sterile  cloth.  If  more  room  is 
required  than  is  provided  by  the  transverse  division  of  mus- 
cles, then,  in  addition,  vertical  incisions  are  made  in  the 
muscle  at  the  outer  end  of  the  transverse  muscular  division. 


Fig.  84. — Typical  thyroidectomy.    Transverse  division  of  preglandular  muscles 

between  clamps. 

Blocking  of  the  Gland  with  Novocain. — The  capsule 
and  the  entire  portion  of  the  gland  which  is  to  be  removed 
are  infiltrated  freely  with  1  : 200  novocain  (Fig.  85) .  In 
exophthalmic  goiter,  in  particular,  the  infiltration  of  the 
gland  with  novocain  is  of  prime  importance  because  there 
is  evidence  that  the  thyroid  discharges  its  secretion  quickly 
in  response  to  nerve  stimuli.  Novocain  blocks  the  sympa- 
thetic nerve  impulses  just  as  it  blocks  the  impulses  of  the 
nerves  of  common  sensation.  Care  must  be  taken  not  to 
include  the  recurrent  nerves  in  the  infiltration.  The  supe- 
rior pole  in  particular  is  well  infiltrated.  If  care  is  exercised 


TECHNIC    OF   OPERATIONS   ON   THYROID   GLAND 


235 


there  is  no  danger  of  puncturing  vessels  nor  of  novocain 
intoxication.  We  have  not  seen  a  single  instance  of  intoxi- 
cation in  our  series. 

Superior  Thyroid  Artery. — In  thyroidectomy  the  superior 
thyroid  arteries  are  isolated  and  ligated  to  prevent  their 
retraction  and  the  resultant  difficulty  of  catching  and  tying 
them.  If  catgut  is  used  it  should  be  made  secure  by 


Fig.  85. — Typical  thyroidectomy.     Infiltration  of  gland  with  novocain. 

passing  it  around  the  artery  with  a  needle.  If  a  free  tie  is 
made  with  catgut  then  in  the  case  of  vomiting  or  coughing 
the  ligature  may  slip  off.  If  a  free  tie  is  to  be  made,  the 
ligature  should  be  silk. 

Resection  of  the  Gland. — In  the  resection  of  the  gland 
itself,  as  in  the  preliminary  steps,  the  points  of  prime 
importance  are  the  maintenance  of  a  clear  field  and  the 
absolute  surgical  control  of  every  phase  of  the  operation. 


236 


THE   THYROID   GLAND 


Fig.  86. — Typical  thyroidectomy.   Posterior  portion  of  gland  which  is  left  after 
thyroidectomy.     Note  thin  layer  of  tissue  covering  trachea. 


PAEA.THYROIP.S. 


Fig.  87. — Typical  thyroidectomy.    Schematic  drawing  in  which  shaded  area 
represents  portion  of  gland  that  is  removed. 

A  margin  of  thyroid  tissue  is  left  along  each  lateral  border 
from  the  upper  to  the  lower  margin  of  the  gland  (Figs.  86, 
87).  To  leave  this  margin  it  is  necessary  to  carry  the 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND     237 

division  through  the  most  vascular  part  of  the  gland. 
Hemorrhage  is  prevented  by  first  grasping  the  tissue  in 
Halsted  forceps,  then  dividing  it.  Many  forceps  are  re- 
quired. The  forceps  are  tied  of!  afterward  with  catgut 
on  a  needle.  The  remainder  of  the  lobes  and  the  isthmus 
are  removed,  usually  in  a  block.  The  division  of  tissue  is 
made  with  a  sharp  knife  in  a  field  so  clear  that  the  para- 
thyroids and  the  recurrent  nerves  would  be  seen  clearly, 
although  in  practice  they  should  never  be  seen,  for  if  they 
are  exposed  the  edema,  and  later  the  scar,  may  interfere 
with  their  function,  this  interference  being  expressed  by 
tetany  and  hoarseness. 

The  Trachea. — The  line  of  cleavage  across  the  trachea 
and  the  larynx  is  developed  in  such  a  way  that  an  undis- 
turbed covering  remains  to  protect  these  structures  (Fig.  86). 
Under  no  circumstance  is  the  surface  of  the  trachea  or  larynx 
touched  by  a  forceps.  A  connective-tissue  covering  of  the 
trachea  and  larynx  is  always  left,  for  if  the  sensory  nerves 
on  the  surface  of  the  trachea  or  larynx  are  disturbed  the 
impulses  are  registered  in  the  brain  as  coming  from  the 
inside  of  the  trachea;  therefore  coughing  and  mucus  are 
produced.  After  the  front  of  the  trachea  and  larynx  have 
been  crossed,  then,  as  a  rule,  all  the  vessels  held  by  the 
forceps  (light  Halsted's)  are  tied  and  a  warm,  moist  gauze 
sponge  is  laid  on  the  field. 

Unusual  Cases. — Occasionally  in  a  hazardous  case  of 
exophthalmic  goiter  the  operation  is  stopped  and  the  wound 
dressed  with  flavine  or  sterile  gauze.  The  next  morning,  if 
conditions  are  favorable,  the  operation  is  completed,  and 
if  the  condition  of  the  patient  is  favorable  at  the  close  of 
this  shorter  operation  the  entire  wound  is  closed.  How- 
ever, if  the  condition  the  next  morning  does  not  warrant 
resection  of  the  second  lobe,  the  wound  is  closed  under 


238 


THE   THYROID   GLAND 


Fig.  .* 


l. — Typical   thyroidectomy.     Suture   of  preglandular   muscles    with 
buttonhole  stitch. 


Fig.  89. — Typical  thyroidectomy.    Vertical  closure  of  preglandular  muscles. 

analgesia  and  local  anesthesia  and  the  patient  sent  home 
for  a  period  of  controlled  rest,  the  second  lobe  being  removed 
at  a  later  date.  If,  after  the  second  lobe  is  resected  on  the 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND 


239 


morning  after  the  first  operation,  the  patient's  condition  is 
in  doubt,  a  flavine  dressing  is  again  applied  and  the  wound 
finally  closed  in  the  afternoon  of  the  same  day  or  the 
following  morning,  according  to  indications. 

To  return  to  the  usual  and  typical  case  of  bilateral 
partial  thyroidectomy — after  the  right  lobe  and  isthmus 


Fig.  90. — Typical  thyroidectomy.     Closure  of  skin  incision  with  clips. 


are  completely  separated,  and  the  attachments  of  the  left 
lobe  to  the  trachea  and  of  the  upper  pole  to  the  larynx  are 
divided  so  as  to  clear  the  trachea  and  larynx,  the  left  lobe 
will  be  so  greatly  mobilized  that  the  forceps  grasping  the 
vessels  may  be  used  to  displace  the  lobe  so  as  to  bring  the 
line  of  proposed  division  of  the  lateral  thyroid  tissue  clearly 
under  the  guidance  of  the  eye.  The  lateral  lobe  is  then 


240 


THE    THYROID   GLAND 


divided  bloodlessly  and  without  bringing  into  vision  the 
parathyroid  or  the  recurrent  nerve.  If  at  any  point  the 
patient  is  disturbed,  additional  novocain  is  at  once  infil- 
trated. The  entire  field  is  inspected  to  determine  whether 
or  not  too  much  thyroid  tissue  has  been  left,  and  whether 
or  not  any  vessels  have  been  overlooked.  If  these  points 
are  satisfactory,  the  anesthetist  raises  the  head  of  the 


.1 


Fig.  91. — Typical  thyroidectomy.    Appearance  of  incision  after  closure. 

patient,  and  the  divided  preglandular  muscles  are  brought 
in  apposition  by  means  of  the  handles  of  the  compressing 
forceps.  The  muscles  are  united  carefully  by  means  of  a 
buttonhole  stitch  made  with  a  curved  needle  and  catgut 
(Fig.  88).  When  both  sides  are  thus  closed,  the  wound  is 
finally  inspected  for  bleeding.  Then  the  vertical  incision 


Fig.  92. — Postoperative  dressing.     Gauze  pad  used  to  protect  back  of  neck 
from  adhesive  plaster. 


Fig.  93. — Postoperative  dressing,  completely  applied. 
16  241 


242  THE   THYROID    GLAND 

is  united  by  suture,  a  small  drain  is  inserted,  and  the  skin 
is  closed  with  clips  (Figs.  89-91).  The  drain  is  removed  the 
following  day. 

SPECIAL  COMMENTS 

How  Much  Gland  Shall  Be  Left? — The  amount  of  gland 
to  be  left  varies  according  to  the  type  of  goiter.  A  block 
of  hyperplastic  gland  (exophthalmic),  ^  inch  square  and 
1  inch  long,  would  probably  have  as  much  functional  value 
as  a  piece  of  colloid  gland  ten  times  as  large,  for  the  reason 
that  the  hyperplastic  gland  consists  almost  entirely  of 
large  columnar  cells,  while  the  colloid  goiter  is  made  up 
mainly  of  colloid  material  and  a  single  layer  of  cubical 
cells.  The  amount  to  be  left  should,  in  general,  be  the 
functional  equivalent  of  a  normal  gland.  This  would  mean 
that  in  hyperthyroidism  only  a  small  portion  of  the  gland 
would  be  left ;  but  in  the  case  of  a  large  colloid  goiter  a  bulk 
larger  than  that  of  a  normal  thyroid  is  required  because  the 
colloid  goiter  is  not  as  active  as  the  normal  gland. 

In  our  earlier  operations  we  usually  erred  by  leaving 
too  much  of  the  gland.  It  was  only  by  trial  and  error  that 
we  finally  realized  that  in  cases  of  hyperthyroidism  a  very 
small  amount  of  gland  is  sufficient.  It  should  be  noted, 
however,  that  the  recurrence  of  symptoms  may  be  due  to 
the  presence  of  some  focus  of  infection. 

What  Part  of  the  Gland  Not  to  Leave. — In  our  earlier 
series  we  followed  Kocher's  advice  and  removed  the  larger 
lobe,  leaving  intact  the  smaller  lobe,  expecting  that  the 
readjustment  of  the  trachea,  larynx,  and  the  smaller  lobe 
would  be  satisfactory  to  the  patient.  For  cosmetic  reasons 
this  proved  very  unsatisfactory  to  the  average  American 
patient  and  we  were  sometimes  obliged  to  resect  the  re- 
maining lobe.  Then  we  resected  both  lobes,  leaving  the 
posterior  capsule  (C.  H.  Mayo)  and  only  a  portion  of  the 


TECHNIC   OF    OPERATIONS   ON   THYROID   GLAND 


243 


upper  and  of  the  lower  poles  on  each  side,  believing  that 
thus  the  parathyroids  would  be  well  protected  and  the 
gland  well  distributed.  Though  this  was  better  than  uni- 
lateral thyroidectomy,  the  poles  would  too  often  display 


Fig.  94. — Enlargement  of  median  lobe  after  operation. 


Fig.  95. — Enlargement  of  the  upper  portion  of  the  median  lobe  after  operation. 

themselves  as  lumps.     This  plan  was  not  entirely  satis- 
factory. 

In  our  first  series,  unless  it  was  enlarged,  the  median 
lobe  was  left.  We  soon  found,  however,  that  occasionally 
after  operation  this  quiescent  lobe  increased  markedly  in 
size,  giving  the  appearance  of  an  Adam's  apple,  which  in 
the  case  of  women,  in  particular,  proved  unpopular.  As  a 
matter  of  precaution  this  lobe  is  now  routinely  removed 
(Figs.  94,  95). 


244  THE    THYROID   GLAND 

Line  of  Division  of  the  Preglandular  Muscles. — We 
have  dealt  with  the  preglandular  muscles  in  many  different 
ways.  A  long  vertical  median  incision,  depending  on 
lateral  traction  for  exposure  of  the  gland,  was  soon  aban- 
doned except  for  adenomata  occupying  a  median  position 
or  for  small  goiters.  For  laterally  developed  lobes  and  in 
exophthalmic  goiter  the  single  median  vertical  division  of 
the  preglandular  muscles  is  too  often  unsatisfactory. 

We  have  tried  the  high  division  of  the  muscle,  employed 
by  C.  H.  Mayo.  For  the  majority  of  cases  this  gives  ade- 
quate exposure,  but  in  some  goiters  it  does  not  always  give 
adequate  opportunity  for  the  dissection  of  the  lower  pole. 

It  is  for  these  reasons  that,  when  more  than  a  vertical 
incision  is  required,  we  have  adopted  the  transverse  division 
described  above. 

Tying  the  four  arteries  outside  the  capsule  occasionally 
results  in  parathyroid  deficiency  because  of  the  limitation 
of  their  blood-supply.  In  about  100  cases  I  made  a  blood- 
less, sharp  knife  separation  of  the  true  capsule  from  the 
surrounding  tissues,  whereby  the  parathyroid  and  the 
recurrent  nerves  were  plainly  exposed  and  were,  therefore, 
left  anatomically  safe.  From  the  anatomic  and  dissectional 
point  of  view  this  is  a  perfect  technic;  but  it  has  one  defect 
which  condemns  it:  occasionally,  although  the  voice  was 
little  or  not  at  all  disturbed  for  some  days  after  the  opera- 
tion, a  hoarseness  appeared  later  and  persisted  in  spite 
of  every  form  of  treatment.  This  was  presumably  due  to 
involvement  of  the  recurrent  nerve  in  the  new  scar  tissue. 

Catching  of  masses  of  thyroid  tissue  by  large  forceps 
and  then  ligating  them  by  needle  and  catgut  en  masse 
was  tried  as  a  means  of  minimizing  the  number  of  ligatures 
and  cutting  down  the  time  of  operation.  From  these  two 
standpoints  this  maneuver  proved  a  great  success;  but  the 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND     245 

pulling  together  of  such  a  mass  of  tissue  occasionally  inter- 
fered with  the  voice.  This  method  was,  therefore,  abandoned 
and  the  more  detailed  method  of  catching  the  individual 
branches  of  the  main  vessels  with  small  forceps  was  adopted. 

Turning  Out  Gland  with  Finger. — In  our  earlier  series 
after  the  gland  was  freely  exposed  the  forefinger  was  slipped 
behind  or  below  or  above  it,  and  the  deeply  lying  gland 
rolled  out  into  view,  thus  greatly  simplifying  the  operation. 
This  did  well  in  most  cases,  but  in  the  case  of  a  bilateral, 
deeply  burrowing  gland,  especially  if  it  is  wedged  tightly 
in  behind  the  larynx  so  that  considerable  force  is  neces- 
sary to  dislodge  it,  the  mere  traction  and  pressure  and 
stretching — that  is  to  say,  the  mechanical  abuse  of  the 
recurrent  nerves — even  though  they  are  not  torn,  may 
block  the  passage  of  nerve  impulses;  and  hence  may  cause 
an  immediate  bilateral  paralysis  of  the  vocal  cords,  which 
will  interfere  with  or  completely  block  the  intake  of  air, 
necessitating  an  immediate  tracheotomy.  Or,  in  the  case 
of  a  partial  paralysis,  respiratory  distress  may  occur  after 
the  operation,  necessitating  the  reopening  of  the  wound, 
even  a  tracheotomy.  The  actual  number  of  such  contre- 
temps may  be  few;  but  one  such  case  seems  the  equiva- 
lent of  many  in  the  impression  it  makes,  more  especially 
if,  following  the  tracheotomy,  bronchopneumonia  and 
later  death  ensue  in  an  otherwise  sound  and  curable 
patient. 

There  is  another  objection  to  this  otherwise  highly 
desirable  maneuver — the  turning  out  of  a  large  thyroid 
from  its  burrow  with  the  ringer,  which  applies  especially 
to  cases  in  which  the  lower  pole  extends  into  the  chest. 
In  such  a  case  everything  may  be  progressing  well,  the 
projecting  lobe  is  rolled  out  carefully,  but  just  as  the 
maneuver  is  completed  a  large  vein,  greatly  stretched, 


246  THE   THYROID   GLAND 

tears,  and  a  full  stream  of  venous  blood  fills  the  hole  vacated 
by  the  ousted  lobe.  The  entire  field  is  at  once  stained 
and  blood  soaked.  The  particular  vessel  is  not  seen. 
Promiscuous  grasping  with  forceps  in  this  black  pool  is 
a  gamble.  Packing  the  entire  cavity  with  gauze  will  quickly 
arrest  the  hemorrhage,  but  meanwhile  the  mechanical 
process  of  gauze  packing  has  torn  neighboring,  equally 
thin-walled  veins,  which  are  waiting  their  opportunity 
to  bleed  when  the  gauze  is  removed.  Everyone  gets  out 
of  this  hole  in  his  own  way,  and  his  own  way  is  usually 
different  in  each  case.  The  best  method  is  prevention  by  a 
controlled  technic,  which  implies  grasping  every  vessel  in 
advance  of  its  rupture  and  the  primary  separation  of  the 
upper  attachment  of  the  lobe  so  that  the  thyroid  will  rise 
spontaneously  with  but  slight  pull  from  above,  not  push 
from  below. 

Catching  and  Tying  Bleeding  Vessels  on  the  Surface 
of  the  Trachea. — If  the  dissection  is  carried  directly  on  the 
trachea  or  larynx,  and  vessels  are  so  divided  that  they 
can  be  caught  only  by  picking  up  and  tying  the  peritracheal 
fascia  with  the  vessel,  thus  including  the  sensory  nerves 
which  enter  the  wall  of  the  trachea,  the  brain  interprets 
this  as  if  there  were  a  foreign  body  in  the  trachea.  There 
will  be  irritation,  coughing,  increased  mucus.  If  there  is  in- 
creased mucus  and  coughing  a  local  tracheitis  will  occasion- 
ally develop.  A  local  tracheitis,  in  turn,  will  occasionally 
terminate  in  bronchitis.  Bronchitis  occasionally  develops 
into  bronchopneumonia.  Bronchopneumonia  may  terminate 
in  death.  Thus  an  innocent  ligature  may  cause  death. 

Contact  with  the  trachea  and  the  larynx  may  be  wholly 
avoided  by  a  sharp,  bloodless  dissection  above  the  line  of 
cleavage,  and  hence  at  a  sufficient  distance  from  the  trachea 
and  larynx  to  tie  the  vessels,  without  including  the  sensory 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND    247 

nerves  of  the  trachea,  leaving  on  the  trachea  an  undis- 
turbed biologic  coat.    This  is  a  most  important  point. 

Interference  with  the  Mechanism  of  Swallowing. — In 
cases  in  which  a  growth  is  thrust  backward  on  each  side 
behind  the  larynx,  and  between  it  and  the  esophagus  and 
the  pharynx,  if  the  enthrusting,  encircling  portion  of  the 
gland  is  dislodged  with  the  finger,  in  some  instances  there 
will  result  interference  with  the  innervation  of  swallowing; 
and  the  consequent  difficulty  in  swallowing  may  persist 
for  several  days.  As  a  result  fluids  and  even  solids  may 
enter  the  respiratory  tract,  causing  paroxysms  of  coughing 
and  even  bronchopneumonia.  A  like  interference  with 
swallowing  may  result  when  the  superior  thyroid  artery 
escapes  and  retreats  above,  just  as  the  inferior  artery  may 
retract  below.  The  interference  with  swallowing  is  due  to 
the  physical  injury  of  the  nerves  in  the  catch-as-catch-can 
process  of  grasping  the  vessel.  The  dissection  may  be  led 
into  this  territory  without  appreciation  of  the  risk.  Caution 
and  prevention  is  the  only  sure  method. 

Respiratory  Obstruction  During  Operation. — With  the 
nitrous  oxid-oxygen  apparatus  oxygen  under  pressure  may 
be  given  at  once  in  case  of  tracheal  obstruction.  We  have 
seen  a  collapsed  trachea  dilated  at  will  with  a  change  in 
pressure  by  means  of  the  gas-oxygen  apparatus.  But  if 
for  any  reason  tracheotomy  is  needed,  a  transverse  small 
opening  between  the  rings  with  a  knife  should  be  made 
early  rather  than  late.  Just  as  soon  as  the  obstruction  is 
removed,  if  conditions  are  favorable,  the  trachea  may  be 
closed  with  a  French  curved  round  needle,  and  the  wound 
closed  as  usual. 

Maintenance  of  a  Clear  Field. — For  every  reason  the 
field  should  be  kept  clear  from  the  start  to  the  finish.  No 
division  of  tissue  should  be  made  through  blood,  especially 


248  THE   THYROID    GLAND 

if  scissors  are  being  used.  We  prefer  the  knife  because  the 
division  is  more  definitive  and  the  chance  for  error  much 
less. 

Blood  in  the  Trachea. — If,  in  an  emergency,  the  trachea 
be  opened  the  inhalation  of  blood  must  be  avoided  what- 
ever may  be  the  cost  in  effort  and  precaution.  This  is 
assured  by  the  control  of  the  local  field  by  hemostats,  and 
by  the  sheer  skill  of  the  first  and  the  second  assistants. 
Inhaled  blood  is  very  likely  to  cause  death  from  broncho- 
pneumonia. 

After  all  these  statements  regarding  the  possible  sources 
of  error  it  would  seem  that  a  thyroidectomy  could  not 
be  made  satisfactorily;  that  the  possibilities  of  danger  are 
innumerable  and  beset  the  operator  on  all  sides.  But  these 
difficulties  cease  to  be  pitfalls  the  moment  the  possibility 
of  their  occurrence  and  the  manner  of  their  avoidance 
have  been  fixed  in  the  mind  of  the  operator  and  in  the 
minds  of  his  staff.  There  has  been  no  tracheotomy  in  our 
last  1080  operations.  By  bearing  in  mind  the  precautions 
indicated  above  we  now  rarely  see  any,  even  the  minor, 
mishaps. 

Delayed  Closure. — As  stated  in  the  section  on  Technic, 
in  any  serious  case  the  wound  is  left  wide  open — completely 
so,  the  divided  muscles  and  tissues  down  to  the  trachea 
and  larynx  and  the  depths  of  the  wound  under  the  clavicle 
— and  the  open  wound  is  dressed  with  1  : 5000  flavine 
gauze  (Fig.  96).  The  advantages  of  this  procedure  are: 

1.  It  shortens  the  time  of  operation.     It  may  cut  off 
the  fatal  last  minute. 

2.  There  is  practically  no  postoperative  pain  or  dis- 
comfort,   thus   it   lessens   by   so   much   the   postoperative 
drive. 

3.  And  most  important:    Leaving  the  wound  open  pre- 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND 


249 


vents  the  absorption  of  wound  secretion.  Aseptic  wound 
secretion  has  always  been  known  to  cause  some  post- 
operative increase  in  temperature  in  normal  non-sensitized 
individuals,  but  in  the  hypersensitized  exophthalmic  goiter 
patients  this  reaction  may  be  multiplied  many  times  and 
become  a  raging  destroying  fever. 

These   wounds   are   closed   under   analgesia   and   local 
anesthesia  without  removing  the  patient  from  bed,  as  soon 


Fig.  96. — Interrupted  operation.     Wound  packed  with  flavine  gauze. 

as  it  seems  safe,  usually  in  the  afternoon  of  the  same  day 
—sometimes  the  next  morning- — occasionally  on  the  second 
day  after  operation  (Figs.  97,  98). 

As  for  infection,  the  wounds  closed  on  the  same  day 
run  a  course  almost  identical  with  those  in  which  primary 
closure  has  been  made.  There  is  a  slight  tendency  after 
the  first  six  hours  to  increased  contamination.  Among 
485  wounds  left  open  on  account  of  their  gravity  the  mor- 
tality was  3.9  per  cent. 


250 


THE    THYROID    GLAND 


Fig.  97. — Interrupted  operation.     Deep  infiltration  of  subcutaneous  tissues 
before  removal  of  flavine  gauze. 


Fig.  98. — Interrupted  operation.  Infiltration  of  muscle-flaps  with  novo- 
cain  before  suture  after  delayed  operation  with  interim  packing  with  flavine 
gauze. 

When  to  Stop  the  Operation. — If  there  is  any  doubt  of 
the  outcome  at  any  point,  that  is  the  moment  to  stop  the 


TECHNIC  OF  OPERATIONS  ON  THYROID  GLAND     251 

operation,  tie  off  the  vessels,  and  dress  the  open  wound 
with  flavine  or  plain  sterile  gauze.  Whether  mistaken  or 
not,  the  operation  can  usually  be  resumed  and  completed  on 
the  following  morning. 

Deception  of  the  Patient. — Patients  are  not  deceived 
as  to  the  tune  of  operation.  If  we  have  their  consent  and 
confidence,  we  go  ahead  so  carefully  that  they  are  not 
aware  of  the  day  and  the  hour  of  operation.  But,  if  a 
patient  demands  to  know  the  proposed  day  and  hour,  he 
is  told.  If,  in  consequence  of  this  information,  his  condi- 
tion becomes  unsatisfactory,  operation  is  deferred.  This 
is  only  an  occasional  experience.  After  the  strain  of  one 
delay  the  patient  usually  is  willing  to  take  a  passive  role. 

x-Ray  Treatment  vs.  Thyroidectomy.— z-Ray  treatment 
does  reduce  the  activity  of  the  thyroid.  It  is  a  simple, 
painless  procedure.  Then  why  not  use  x-ray  to  the  exclu- 
sion of  other  procedures?  Because  of  the  following  dis- 
advantages : 

(a)  The  dose  required  to  produce  a  given  effect  is  at 
best  a  guess. 

(6)  Relapses  are  common. 

(c)  The  delay  in  unsuccessful   cases  leads  to   serious 
damage  to  certain  organs — the  myocardium,  liver,  nervous 
system,  etc. 

(d)  In  case  of  operation  later  the  scar  tissue  and  adhe- 
sions caused  by  the  x-ray  are  a  handicap.     The  dilemma 
in  the  use  of  the  x-ray  is:    Myxedema  or  relapse.     If  the 
dose  is  sufficient  to  kill  all  the  thyroid  cells,  myxedema 
results;  if  the  dose  does  not  kill  the  cells,  they  recover  and 
there  is  relapse. 

Indications  for  Ligation. — In  this  clinic  ligation  is  em- 
ployed only  as  a  preliminary  to  thyroidectomy.  Double 
ligation  rarely  cures,  but  as  is  the  case  after  x-ray  treat- 


252  THE   THYROID    GLAND 

ment,  there  is  a  tendency  to  relapse.  And  when  relapse 
occurs,  we  have  lost  the  nicest  step  in  the  graded  operation. 

z-Ray  might  be  used  instead  of  ligation  as  a  part  of  a 
graded  operation,  except  for  the  uncertainty  of  the  extent 
to  which  it  has  destroyed  the  thyroid  tissue. 

To  What  is  the  Good  Effect  of  Ligation  Due?— Certainly 
not  to  the  diminution  of  the  blood-supply,  for  no  matter 
how  soon  or  how  late  after  ligation  the  thyroidectomy  is 
performed,  the  local  blood-supply  is  found  to  be  diminished 
but  little,  if  at  all.  In  fact,  it  often  seems  as  if  the  blood- 
supply  after  ligation  is  richer  because  of  all  the  developed 
collateral  branches.  I  am  of  the  opinion  that  the  greater 
part  of  the  benefit  from  ligation  is  the  result  of  a  break 
in  the  nerve  supply  of  the  thyroid,  since  the  principal  sym- 
pathetic nerves  run  in  the  walls  of  the  superior  thyroid 
arteries. 

What  is  the  Indication  for  Thyroidectomy? — Diagnosis 
of  hyperthyroidism  is  the  indication  for  thyroidectomy.  We 
believe  this  because  if  we  wait  to  try  out  the  rest  cure,  in 
case  rest  fails  to  cure,  and  this  is  true  in  too  many  instances, 
the  patient  has  sustained  serious  additional  damage,  perhaps 
permanent  damage,  to  the  myocardium,  to  the  liver,  to  the 
nervous  system;  his  life  has  been  shortened;  the  difficulty  of 
the  operation  has  been  increased;  and  much  time  has  been 
lost. 

It  is  only  within  recent  years  that  we  have  been  able 
to  put  hyperthyroidism  in  the  class  with  appendicitis  as  to 
operability,  but  now  the  mortality  of  thyroidectomy  is 
almost  as  low  as  the  mortality  of  appendectomy.  In  view 
of  the  comparatively  short  stay  in  the  hospital,  the  slight 
risk,  the  inconsequential  scar,  we  are  prepared  to  accept 
the  dictum  "operate  on  diagnosis." 


CERTAIN  POSTOPERATIVE  COMPLICATIONS  OF  OPERA- 
TIONS ON  THE  THYROID  GLAND* 

G.  W.  CRILE  AND  W.  E.  LOWER 


Attachment  of  the  Scar  to  the  Trachea. — In  certain 
rare  instances  the  scar  becomes  attached  to  the  trachea 
at  the  point  of  drainage.  An  objectionable  consequence 
of  this  scar  is  its  rise  and  fall  during  swallowing,  coupled, 
in  some  instances,  with  a  slight  pulling  sensation.  The 
complaint  of  the  patient,  however,  is  nearly  always  directed 
against  the  appearance  rather  than  against  the  pulling  sen- 
sation. After  tracheotomy  the  scar  is  sometimes  attached 
closely  to  the  line  of  healing  of  the  opening  in  the  trachea. 
In  any  case  such  a  scar  is  easily  relieved  by  excision  of  the 
scar  tissue  down  to  the  normal  tissue,  the  separated  fascia 
and  muscle  being  approximated  so  that  a  normal  super- 
imposed tissue  intervenes  between  the  trachea  and  the  skin. 
The  skin  is  closed  with  skin-clips.  The  operation  is  slight; 
the  discomfort,  negligible;  the  result  is  invariably  good. 

Unevenness  of  the  Neck  after  Thyroidectomy  Due  to 
Permanent  Absorption  or  Displacement  of  Tissue  Made 
by  the  Long-continued  Pressure  of  the  Growth. — After 
the  removal  of  a  large  deforming  goiter  which  has  left 
inequalities  in  the  contour  of  the  neck  the  occasional  patient 
develops  an  uncontrollable  longing  for  the  perfect  neck  of 
her  girlhood  days;  rather  of  the  girlhood  days  of  her  friends, 
for  her  own  neck  was  always  full,  uneven,  deformed.  After 
years  of  skilful  shading,  draping,  and  posing,  as  skilful 
as  the  revealing  and  concealing  adaptations  of  animals 

*  Reprinted  from  Am.  J.  Surg.,  1921,  xxxv,  317-318. 
253 


254  THE   THYROID    GLAND 

in  struggle  and  survival,  it  is  not  unnatural  that  in  these 
patients  the  sensibilities  are  so  heightened,  and  the  hope 
for  a  perfect  neck  is  so  intense,  that  special  consideration 
is  demanded.  In  such  a  case  after  every  attempt  has  failed 
to  persuade  the  patient  that  she  has  already  made  a  good 
bargain  with  fate,  we  have  reopened  the  neck,  and  have 
reflected  back  the  skin  rather  widely  so  as  to  give  an  oppor- 
tunity for  sliding  fascia  or  muscle  and  transplanting  fat 
from  elevation  to  depression.  In  short,  we  have  modeled 
a  new  neck  which  in  its  lines  and  depressions  approximates 
as  nearly  as  possible  the  neck  of  youth. 

Postoperative  Hoarseness. — In  the  occasional  case 
hoarseness  persists.  This  is  usually  overcome  spontaneously 
and  very  rarely  remains  permanent.  In  our  earlier  series 
hoarseness  was  much  more  common,  and  in  every  instance 
its  cause  could  be  traced.  The  most  common  cause  was 
grasping  or  making  traction  on  the  nerves  in  the  control 
of  bleeding.  The  vessels  in  apposition  to  the  recurrent 
nerves  or  the  parathyroid  would  occasionally  escape  and 
retract,  carrying  their  bleeding  ends  behind  the  position 
of  the  parathyroid,  the  blood  meanwhile  flowing  freely, 
hiding  the  vessel.  The  securing  of  the  bleeding  end  is  aptly 
likened  to  catching  a  squid.  No  squid  was  ever  more 
beclouded  nor  more  elusive  than  the  bleeding  superior 
or  inferior  thyroid  artery.  In  the  pursuit  it  is  best  to 
expose  the  spurting  end  and  secure  it  alone. 

Another  cause  of  hoarseness  was  the  rough  tearing  out 
of  the  goiter  with  the  finger  from  the  side  and  from  behind, 
or  the  use  of  the  large  Kocher  barbed  forceps  which  gathered 
in  the  tissue  in  the  neighborhood.  Still  another  cause  was 
the  complete  exposure  of  the  recurrent  nerve  during  the 
operation,  leaving  it  in  contact  with  the  process  of  healing 
and  cicatrization  of  the  wound. 


COMPLICATIONS   OF   OPERATIONS   ON   THYROID    GLAND      255 

Aphonia. — Occasionally  a  patient  returns  from  the 
operating  room  serene,  but  voiceless;  or  after  some  days  of 
clear  voice,  she  becomes  abruptly  aphonic.  With  these 
psychic  voice  failures  the  surgeon  gives  himself  no  con- 
cern. In  due  course  the  voice  returns  unheralded  and  as 
abruptly  as  it  disappeared. 

Singing  and  Thyroidectomy. — A  singer  with  a  gradually 
enlarging  goiter  apparently  is  in  a  dilemma.  If  the  goiter 
is  left  alone  there  is  the  ever-present  possibility  that  the 
strain  on  the  vocal  cords  will  be  increased  and  the  voice 
altered.  In  any  case  the  stage  appearance  is  affected. 
On  the  other  hand,  there  is  the  fear  that  the  removal  of 
the  goiter  will  change  the  physical  environment  of  the 
larynx  sufficiently  to  alter  the  quality  of  the  voice,  and  the 
possibility  of  temporary  huskiness  or  hoarseness,  after  even 
the  best  planned  operation,  is  increased  in  the  case  of  a 
highly  developed  voice,  and,  of  even  more  importance, 
in  the  case  of  a  highly  developed  temperament.  The  sur- 
geon's burden  of  responsibility  is  increased  by  the  con- 
sciousness that  if  the  artist  later  loses  prestige  from  any 
cause,  even  including  the  inevitable  effect  of  increasing 
years,  the  blame  will  probably  be  placed  upon  the  opera- 
tion. However,  by  the  avoidance  of  each  of  the  dangerous 
maneuvers  described  above  we  now  seldom  note  any 
essential  alteration  in  the  voice,  even  immediately  after 
the  operation.  In  fact,  it  has  been  our  experience  that 
even  the  singing  voice  is  more  often  improved  than  injured; 
a  certain  tendency  to  flatness  is  replaced  by  resonance; 
certainly  the  flat,  speaking  voice,  so  commonly  resulting 
from  the  pressure  of  the  massive  goiters  is  greatly  improved. 
Taken  as  a  whole,  we  believe  that  the  average  effect  on 
the  voice  is  an  improvement. 

Intermittent  Respiratory  Block. — An  inspiratory  block 


256  THE    THYROID   GLAND 

occurring  principally  at  night  at  irregular  intervals  is  an 
occasional  sequel.  This  is  due  to  adductor  paralysis,  as  a 
result  of  which  the  vocal  cords  are  floated  out  by  the  cur- 
rent of  expired  air,  but  block  the  incoming  current  of  air 
in  somewhat  the  same  manner  as  the  aortic  valves  block 
the  blood  from  returning  to  the  heart,  or  as  the  gates  of  a 
lock  block  the  flow  of  water.  The  effect  of  this  distressing 
complication  is  due  in  part  to  the  sensation  of  suffocation 
and  its  resultant  fear  as  well  as  to  the  actual  want  of 
air. 

False  Alarms. — For  some  time  after  thyroidectomy  the 
patient's  low  thresholds  lead  to  needless  worries  from  mis- 
taking an  enlarged  lymphatic  gland  for  goiter;  from  mis- 
taking pharyngitis  or  laryngitis  for  some  feared  "inward" 
trouble;  from  interpreting  worry  and  sleeplessness,  result- 
ing from  normal  causes,  as  an  "inward  goiter."  Any  local 
pain,  stiffness,  pull,  hoarseness,  depression,  or  inequality 
may  cause  uneasiness  or  apprehension.  Usually  a  word 
of  reassurance,  given,  however,  only  after  a  careful  re- 
examination,  is  sufficient. 

Postoperative  Infection.— Because  of  the  large,  loose, 
partially  occupied  space  in  the  neck  following  the  removal 
of  large  thyroids;  and  in  particular  because  of  the  facility 
for  the  pooling  of  wound  secretion  under  the  clavicle  and 
because  of  the  necessity  for  drainage,  infection  is  occasionally 
seen.  We  have  found  that  on  the  first  appearance  of  infec- 
tion it  is  best  to  open  the  neck  widely  and  promptly  and 
sterilize  the  entire  field  of  operation  by  hot  packs  and  Dakin's 
fluid,  and  making  an  early  secondary  closure  in  accord- 
ance with  the  method  which  was  so  extensively  and  suc- 
cessfully practised  in  the  war.  The  point  of  prime  impor- 
tance is  immediate  and  wide  opening  and  exposure  of  the 
entire  wound  to  treatment. 


COMPLICATIONS   OF   OPERATIONS   ON   THYROID    GLAND      257 

The  Prevention  of  Postoperative  Enlargement  of  the 
Remaining  Thyroid  Tissue  After  the  Removal  of  Colloid 
Goiters  or  of  Colloid  Adenomata. — After  the  removal  of 
large,  plain  goiters,  especially  in  obese  women,  the  portion 
of  the  gland  which  is  left  often  retains  sufficient  growth- 
energy  to  rebuild  a  goiter  of  large  size  within  a  few  years. 
These  patients  are  disappointed,  and  their  confidence  in 
reoperation  is  not  easily  established — nor  should  it  be. 
Basing  our  practice  on  the  easy  control  of  endemic  goiter 
by  the  administration  of  iodin,  we  now  give  iodin  for  not 
less  than  one  year  after  thyroidectomy  to  all  goiter  patients 
except  cases  of  exophthalmic  goiter  or  of  toxic  adenomata. 
Thus  far  the  redevelopment  of  plain  goiters  seems  to  have 
been  effectively  prevented  by  this  measure. 

Thyroid  Deficiency. — In  perhaps  1  out  of  500  cases  the 
thyroidectomy  is  followed  by  symptoms  of  thyroid  de- 
ficiency. This  complication  is  easily  controlled  not  by 
iodin,  but  by  the  intermittent  administration  of  thyroid 
extract.  In  course  of  time,  for  some  unknown  reason, 
the  symptoms  of  deficiency  permanently  disappear. 

Parathyroid  Deficiency. — Parathyroid  deficiency  is  more 
frequently  encountered  than  thyroid  deficiency,  and  its 
management  is  more  difficult.  This  complication  has  two 
phases,  the  first  appearing  immediately  after  operation, 
the  second  after  the  patient  returns  home. 

The  immediate  symptoms  of  parathyroid  deficiency 
are  the  characteristic  signs  of  tetany  beginning  with  slight 
stiffness  or  merely  tingling  sensations  in  the  fingers  and 
progressing  to  intermittent  tonic  spasms.  The  causes  are 
several — the  removal  of  the  parathyroids  at  the  operation, 
wound  infection,  or  interference  with  the  blood-supply  of 
the  parathyroids,  any  of  which  may  result  in  a  suspension 
of  function.  Our  pathologist,  therefore,  is  charged  with 

17 


258  THE    THYROID    GLAND 

the  duty  of  searching  every  specimen  to  ascertain  whether 
or  not  the  parathyroid  has  been  removed.  The  patholo- 
gist has  found  three  in  the  last  269  operations.  As  a 
result  of  the  earlier  reports  we  first  changed  our  technic 
so  as  to  see  the  parathyroids  and  thus  assure  their  retention. 
This  technic  had  several  serious  defects:  first,  in  exposing 
the  parathyroids  there  was  the  danger  of  blocking  their 
blood-supply  in  the  course  of  operation  itself;  second,  in  the 
course  of  healing,  either  the  gland  itself  or  its  blood-supply 
might  be  strangled  by  the  enveloping  scar;  if  infection 
occurred  the  blood-supply  of  the  exposed  parathyroids  or 
the  parathyroids  themselves  might  be  affected.  In  one 
case  we  have  reason  to  believe  that  infection  precipitated 
an  acute  tetany.  Another  danger  which  threatens  the 
parathyroid  in  the  course  of  operation  is  its  possible  inclu- 
sion with  a  mass  of  thyroid  tissue  in  heavy  barbed  forceps 
or  within  a  suture  passed  around  the  gland  by  a  needle. 
These  measures  must  be  regarded  as  a  menace  and  avoided 
as  a  routine. 


TREATMENT  OF  INOPERABLE  CANCER  OF  THE 
THYROID  BY  DECOMPRESSION 

GEORGE  W.  CRILE 


IN  our  series  of  operations  on  the  thyroid  1.8  per  cent, 
have  been  for  cancer.  In  addition  to  these  cases  of  frank 
cancer  there  is  also  a  group  of  cases  in  which  neither  by 
clinical  nor  microscopical  criteria  can  the  diagnosis  be  made 
with  certainty.  The  end-results  of  the  surgical  treatment  of 
the  cases  in  which  thyroidectomy  was  possible  will  be  made 
at  a  later  tune. 

The  special  problem,  however,  in  a  consideration  of  the 
surgical  treatment  of  cancer  of  the  thyroid  gland  is  not  con- 
cerned with  the  cases  in  which  the  growth  can  be  removed, 
but  rather  with  the  inoperable  cases  in  which  the  patient 
is  suffering  great  distress  from  obstruction  and  partial 
asphyxiation.  We  believe  that  this  problem  has  been  par- 
tially solved  satisfactorily  by  the  application  of  the  following 
operative  procedure:  Under  analgesia  and  local  anesthesia, 
through  a  median  collar  incision,  the  preglandular  muscles 
are  divided  for  the  entire  distance  across  the  tumor.  On 
exposure  of  the  preglandular  muscles  it  is  at  once  noted  that 
there  is  a  tenseness  which  is  not  usually  seen  in  cases  of 
ordinary  goiter.  This  tenseness  is  due  to  the  fact  that  the 
preglandular  muscles  are  holding  in  restraint  a  growing  car- 
cinoma, thus  reflecting  the  pressure  back  upon  the  trachea. 
As  the  muscles  are  divided  the  gland  itself  protrudes  freely, 
thus  relieving  the  back  pressure,  and  in  consequence  relieving 
the  patient  from  the  distressing  symptoms.  Nothing  more 
is  done  excepting  to  close  the  skin,  leaving  the  muscles 

259 


260 


THE    THYROID    GLAND 


retracted,  for  this  is  merely  a  decompression  operation  de- 
signed only  to  give  temporary  relief. 

A  very  pleasant  surprise  occurred  in  one  of  these  cases : 
The  patient,  a  woman  sixty  years  of  age,  presented  herself 
with  a  hard,  deeply  situated,  fixed,  infiltrating  growth  of 
moderate  size  extending  across  the  median  line.  She  stated 
that  she  had  first  noted  the  beginning  of  this  growth  one 


Fig.  99. — Patient  five  months  after  decompression  operation  for  carcinoma  of 

the  thyroid. 

year  before,  that  for  the  first  six  months  it  had  increased  in 
size  rather  rapidly,  but  for  the  last  few  months  there  had 
been  little  change  in  the  external  appearance.  During  the 
preceding  month,  however,  her  voice  had  become  hoarse 
and  she  had  suffered  occasional  spells  of  choking. 

At  operation,  upon  division  of  the  preglandular  muscles, 
it  was  found  that  the  entire  thyroid  gland  was  invaded  and 


261 

that  the  adjacent  tissues  were  infiltrated  with  extensions 
from  the  carcinoma.  The  operation  was,  therefore,  confined 
to  the  decompression  procedure  described  above. 

During  the  five  months  since  her  operation  this  patient 
has  been  under  x-ray  treatment  by  Dr.  B.  H.  Nichols.  The 
cancerous  goiter  cannot  be  palpated.  She  has  been  entirely 
relieved  from  her  choking  spells  and  from  the  local  discom- 
fort. An  acute  myxedema  has  developed,  the  result  of  the 
extensive  involvement  of  the  thyroid  tissue  in  the  cancer, 
her  basal  metabolism  being  reduced  to  — 14,  and  she  is  there- 
fore receiving  thyroid  extract  to  supply  this  deficiency 
(Fig.  99). 

While  it  is  still  too  early  to  make  any  prediction  as  to 
the  end-result  in  this  or  in  similar  cases,  nevertheless,  this 
patient  who  is  now  confortable  and  apparently  free  from 
cancer,  certainly  owes  the  respite  and  relief  to  this  decom- 
pressing operation  and  the  x-ray  therapy. 


THE   POSTOPERATIVE   TREATMENT   OF   THE   EXOPH- 
THALMIC GOITER  PATIENT 

FRANK  S.  GIBSON 


AN  intelligent  postoperative  handling  of  the  exoph- 
thalmic goiter  patient  must  be  expectant  in  character  and 
based  upon  a  knowledge  of  the  probable  reaction  each 
individual  may  show  to  each  particular  form  of  stimuli. 
This  knowledge  is  obtained  from  the  significant  facts 
revealed  in  the  patient's  history,  the  physical  examination, 
and  the  laboratory  tests.  Sum  these,  add  certain  incidents 
from  past  experience,  and  proceed  to  treat  the  patient 
well  in  advance  of  any  approaching  complication. 

Consider  a  patient  who  presents  herself  for  operation 
with  the  complaint,  among  others,  that  for  some  months, 
owing  to  an  irreparable  emotional  and  nervous  disturbance, 
she  has  avoided  the  entertainment  of  her  most  intimate 
friends  and  even  at  times  the  companionship  of  her  own 
family.  Would  it  be  wise  to  permit  the  attendance  of  the 
family  and  friends  in  the  sick  room  of  such  a  case  when  the 
quiet  attention  of  the  physician  and  nurse  in  charge  insures 
a  restful,  tractable  attitude?  This  incident,  though  it  seems 
trivial,  serves  to  exemplify  a  course  of  procedure  which, 
when  exercised  in  every  detail,  renders  the  cure  of  even  the 
most  acute  exophthalmic  goiter  patient  simply  an  interest- 
ing psychic  and  physical  problem  with  the  happy  assurance 
of  a  good  result. 

Intelligent  and  anticipatory  treatment  has,  therefore, 
become  our  slogan,  and  we  use  the  word  "intelligent" 
because  the  initiation  of  all  precautionary  measures  in 

263 


264  THE   THYROID    GLAND 

whose  efficacy  one  might  have  confidence  would  add  a 
needless  burden  to  the  patient.  On  the  other  hand,  having 
previously  determined  the  points  of  least  resistance  in 
each  individual  by  simple,  commonplace  methods,  the 
reserve  may  be  strengthened  at  these  points  before  even 
the  first  lines  of  the  defense  have  been  broken. 

A  DISCUSSION  OF  SOME  METHODS  OF  PROCEDURE  WHICH  ARE 
SIMPLE,  APPLICABLE  TO  ALL  POSTOPERATIVE  CASES,  AND 
THEREFORE  ARE  ROUTINELY  EMPLOYED 

During  anesthesia  and  immediately  following  an  opera- 
tion all  patients  perspire  quite  freely,  rendering  the  opera- 
tive clothing  wet  and  cold.  These  garments  are  removed 
and  warm  dry  flannels  substituted  before  the  patient  is 
taken  from  the  operating  room,  and  the  bed  to  which  the 
patient  is  to  be  returned  is  warmed  with  hot-water  bot- 
tles. 

This  dehydration  of  the  tissues  occurring  coincident 
with  the  operative  procedure,  coupled  with  a  temporary 
abstinence  from  the  administration  of  water  by  mouth, 
plays  a  considerable  part  in  the  incidence  of  the  hyper- 
pyrexia  so  frequently  seen  after  operations  for  exophthalmic 
goiter.  This  situation  is  met  by  the  subcutaneous  adminis- 
tration, under  the  pectoral  muscles,  of  normal  saline  in 
quantities  ranging  from  1000  to  2000  c.c.  The  beneficial 
results  which  have  been  seen  to  follow  the  flooding  of  the 
body  tissues  with  water  in  this  manner  has  brought  the 
procedure  into  routine  use  as  a  postoperative  measure. 

It  is  extremely  important  that  these  patients  be  kept 
composed  and  comfortable,  as  a  nervous,  suffering  patient 
soon  becomes  restless  and  irritable,  a  condition  which 
predisposes  to  and  abets  the  exaggerated  postoperative 
reaction.  The  patients  are  placed  in  bed  in  the  sitting 


POSTOPERATIVE  TREATMENT  OF  EXOPHTHALMIC  GOITER      265 

posture,  with  the  head  and  knees  slightly  flexed.  Pillows 
are  banked  around  the  body  so  as  to  permit  complete 
relaxation  without  danger  of  moving,  as  these  patients 
fear  the  slightest  movement  which  may  cause  pain. 

The  hypodermic  injection  of  a  sedative  suitable  to  the 
patient's  needs  and  condition  is  administered  immediately 
upon  return  from  the  operating  room,  and  repeated  as  often 
as  necessary  to  secure  comfort.  Morphin  sulphate  in  |- 
grain  doses  is  the  drug  and  amount  commonly  used,  and 
is  found  to  be  well  tolerated  when  given  in  conjunction 
with  hypodermoclysis,  even  in  cases  that  have  an  idiosyn- 
crasy against  the  drug  when  given  alone — that  is,  without 
watering  the  tissue. 

Ice-bags  to  the  number  of  six  are  placed  about  the  body 
external  to  the  sheet  or  blanket  which  covers  the  patient, 
one  over  the  heart,  the  remainder  over  the  loins  and  extremi- 
ties. A  cold  wet  cloth  is  placed  over  the  face  and  forehead. 
These  we  consider  to  be  of  distinct  aid  in  stabilizing  the 
body  temperature. 

Water  is  urged  as  soon  as  the  patient  is  able  to  take  it, 
soups  and  soft  foods  on  the  day  of  operation  and  the  follow- 
ing day,  after  which  any  form  of  food  listed  on  the  regular 
hospital  menu  exclusive  of  highly  seasoned  foods,  meat 
and  coffee,  may  be  given;  the  latter  restriction  in  diet 
being  advised  for  a  period  of  from  three  months  to  one 
year,  or  even  longer,  depending  on  the  severity  of  the 
case. 

The  postoperative  period  of  absolute  confinement  in 
bed  varies  from  two  days,  in  the  case  of  a  small  adenoma, 
to  eight  days,  in  the  case  of  severe  exophthalmic  goiter, 
after  which  the  patients  are  allowed  to  be  up  for  two  hours 
each  morning  and  afternoon.  They  are  discharged  from  the 
hospital  after  from  six  to  twelve  days,  with  instructions  to 


266  THE   THYROID   GLAND 

avoid  all  social  activity  for  the  succeeding  six  months,  and 
during  that  time  to  go  to  bed  early  at  night,  to  rise  late, 
and  also  to  rest  each  afternoon  from  two  to  five  o'clock. 
It  is  made  clear  to  the  patient  that  he  himself  has  an  im- 
portant role  to  play  in  the  convalescence  and  that  the 
result  obtained  is  in  a  large  part  dependent  upon  his  hearty 
co-operation.  The  above  rules  of  government  for  the 
convalescent  period  are  not  applicable  to  the  patients  with 
adenomatous  type  of  goiter,  for  whom  only  such  general 
measures  as  will  tend  to  improve  the  general  welfare  are 
initiated  or  advised. 

Medication. — The  postoperative  administration  of  drugs 
is  not  routine  in  character,  but  depends  entirely  upon  the 
patient's  condition.  Following  the  convalescent  period 
no  medicine  whatsoever  is  advised  in  cases  of  exophthalmic 
goiter.  Patients  with  diffuse  colloid  or  colloid  adenomatous 
goiters  are  given  a  prescription  for  the  syrup  of  ferrous 
iodid,  to  be  taken  in  15-minim  doses  in  a  glass  of  water 
once  daily  during  alternate  months  for  a  period  of  one 
year.  This  medication  will  aid  in  the  re-establishment  of 
the  normal  physiologic  function  of  the  gland  and  will  pre- 
vent an  early  compensatory  hypertrophy. 

Care  of  the  Wound. — Considerable  drainage  of  serum 
from  the  wound  usually  occurs  during  the  first  twelve 
hours  after  operation,  and  it  promotes  the  comfort  of  the 
patient  to  change  the  dressing  at  the  end  of  this  time  and 
each  twenty-four  hours  thereafter  until  the  wound  is  com- 
pletely healed.  The  small  soft-rubber  drain  is  removed 
after  twenty-four  hours.  The  clips  which  are  used  to  approx- 
imate the  skin  are  removed  on  the  third  postoperative  day, 
thus  avoiding  any  scar  save  the  thin  white  line  which 
marks  the  site  of  the  incision. 


POSTOPERATIVE  TREATMENT  OF  EXOPHTHALMIC  GOITER      267 

METHODS  FOR  THE  TREATMENT  OF  CERTAIN  POSTOPERATIVE 
COMPLICATIONS 

The  acute  postoperative  reaction  which  formerly  was 
so  frequently  encountered  in  the  exophthalmic  goiter 
patient  is  now  seldom  seen,  as  this  unfortunate  operative 
sequel  has  been  almost  eliminated  by  the  preventive  meas- 
ures employed  during  and  immediately  after  the  operation; 
by  the  avoidance  of  suboxidation  anesthesia,  that  is,  surgical 
anesthesia,  and  the  substitution  of  nitrous  oxid  analgesia; 
by  the  minimizing  of  nervous  exhaustion  and  shock  by 
operating  on  the  severe  cases  in  their  rooms;  by  the  avoid- 
ance of  long  operation;  by  the  prevention  of  absorption 
of  wound  secretion,  and  by  the  multiple  stage  operation. 

The  signs  which  these  cases  present  when  handled  in 
any  other  manner  more  disturbing  to  the  general  nervous 
mechanism  are  collectively  spoken  of  as  the  "postoperative 
reaction,"  which  is  evidenced  by  hyperpyrexia,  tachycardia, 
extreme  restlessness,  nausea,  vomiting,  and  diarrhea.  In 
some  cases  there  may  also  be  an  acute  urinary  suppression. 
While  it  is  true  that  such  a  condition  is  now  seldom  seen, 
nevertheless  all  cases  of  the  more  severe  type  are  treated 
as  though  potentially  capable  of  developing  this  condition. 
Following  the  operation  six  ice-bags  are  placed  about  the 
body  of  the  patient  external  to  the  covering  sheet.  This 
number  is  doubled  with  each  degree  in  rise  of  temperature 
up  to  102°  F.  Should  this  procedure  fail  to  control  the 
temperature  and  it  reaches  103°  F.,  an  ice-pack  is  employed 
in  which  the  patient  remains  until  the  temperature  has 
regressed  to  99°  F.  (Fig.  100). 

The  technic  of  the  ice-pack  is  simple.  The  mattress  is 
first  covered  with  rubber;  the  patient  is  rolled  in  a  linen 
sheet  and  covered  with  a  large  rubber  blanket.  From  150 
to  200  pounds  of  crushed  ice  are  heaped  upon  the  rubber 


268 


THE    THYROID    GLAND 


blanket  and  snugly  packed  about  the  patient.  An  ice- 
cap is  applied  to  the  head.  An  electric  fan  placed  at  the 
foot  of  the  bed  with  the  breeze  directed  toward  the  head 
will  hasten  the  cooling  process. 

The  rubber  blankets  will  keep  the  patient  dry  without 
interfering  with  the  cooling  process,  a  fact  which  must  be 
remembered,  for,  if  the  patient  becomes  wet,  chilling  will 


V 


r\ 


Fig.  100. — Chart  illustrating  control  of  postoperative  hyperthyroidism  by  ice- 
packs. 

follow  and  cause  great  discomfort,  while  if  the  patient  be 
kept  dry  the  temperature  may  be  reduced  to  any  desired 
point  without  complaint.  The  temperature  falls  at  about 
the  rate  of  2°  F.  per  hour,  and  should  be  checked  carefully 
at  least  every  twenty  minutes.  Certain  emaciated  cases 
tend  to  respond  very  much  more  rapidly  than  those  possess- 
ing a  more  generous  covering  of  lipoid  tissue,  and  in  such 


POSTOPERATIVE  TREATMENT  OF  EXOPHTHALMIC  GOITER      269 

cases  the  temperature  reduction  may  continue  after  the 
patient  has  been  removed  from  the  pack  until  such  a  degree 
of  subnormality  is  reached  as  to  render  the  situation  alarm- 
ing. Aside  from  this  one  feature  the  procedure  is  wholly 
without  danger. 

The  tachycardia  which  is  seen  in  these  cases  is  cer- 
tainly of  nervous  origin,  and  is  rarely  associated  with  any 


Fig.  101. — Charts  showing  control  of  postoperative  tachycardia  by  digitalin. 

sign  of  a  failing  myocardium.  Even  immediately  preceding 
a  fatal  outcome  it  is  rarely  possible  to  demonstrate  any 
sign  of  an  acute  cardiac  dilatation,  nevertheless  a  hypo- 
dermic injection  of  digitalin,  grain  -27,  is  administered 
each  hour  in  the  hope  that  it  may  strengthen  the  myo- 
cardium (Fig.  101).  Morphin  in  |-grain  doses,  administered 
hypodermically,  sufficiently  often  to  overcome  the  nervous, 


270  THE   THYROID    GLAND 

restless  apprehensiveness  of  the  patient,  is  certainly  of  very 
much  greater  benefit. 

Vomiting  and  diarrhea  are  but  another  expression  of 
the  instability  of  the  nervous  mechanism.  They  are  best 
combated  by  giving  the  gastro-intestinal  tract  a  complete 
rest,  withholding  all  fluids  and  nourishment  by  mouth 
until  the  condition  is  ameliorated,  and  relying  upon  hypo- 
dermoclysis  to  the  amount  of  3000  to  4000  c.c.  of  normal 
saline  daily  for  the  fluid  intake. 

Acute  cardiac  decompensation  and  auricular  fibrilla- 
tion are  a  not  uncommon  complication  in  advanced  cases 
of  exophthalmic  goiter  and  in  adenomatous  patients  with 
chronic  myocarditis.  As  stated  in  the  section  on  pre- 
operative  treatment  such  cases  receive  one  or  more  courses 
of  digitalis  before  operation,  that  is,  tincture  of  digitalis  in 
doses  of  20  minims  or  less,  administered  every  four  hours 
for  eight  to  twelve  doses,  after  which  a  rest  period  of  from 
twenty-four  to  forty-eight  hours  is  allowed,  when  the  course 
is  repeated.  In  certain  cases  this  is  supplemented  by  the 
administration  of  digitalin  or  strophanthin,  the  former  hy- 
podermically  in  ^Vgrain  doses  each  hour,  the  latter  intra- 
venously, \  mg.  in  5  c.c.  of  saline,  given  in  two  equal  doses 
separated  by  a  fifteen-minute  interval. 

The  only  other  adjuvant  of  importance  in  the  treat- 
ment of  this  condition  is  complete  rest,  in  the  attainment 
of  which  the  value  of  morphin  must  not  be  forgotten. 

Tracheitis,  bronchitis,  and  pneumonia  are  occasional 
postoperative  incidents.  For  pneumonia  the  usual  sup- 
portive measures  are  employed :  spiritus  frumenti,  tincture 
of  digitalis,  large  quantities  of  water  by  mouth  and  hypo- 
dermically  if  necessary  for  the  maintenance  of  a  high  urinary 
output.  The  inhalation  of  steam  mixed  with  fumes  from 
the  compound  tincture  of  benzoin  is  a  great  aid  in  over- 
coming the  collection  of  mucus  in  the  bronchial  tree. 


POSTOPERATIVE  TREATMENT  OF  EXOPHTHALMIC  GOITER      271 

Postoperative  hemorrhage  is  controlled  by  opening  the 
wound,  tying  off  the  bleeding  point,  and  closing  at  once; 
or  if  the  condition  seems  to  be  due  to  a  general  oozing, 
evacuating  the  clot,  packing  the  wound  open,  and  making  a 
secondary  closure  after  twenty-four  hours.  The  latter  con- 
dition has  been  seen  but  rarely  since  the  initiation  of  the 
two-stage  operation.  The  loss  of  blood  in  either  case  may  be 
considerable  within  a  very  short  time,  and  therefore  imme- 
diate attention  is  demanded,  for  these  patients  cannot  easily 
withstand  even  a  moderate  loss  of  blood.  For  this  reason  in 
our  clinic  it  has  become  a  routine  procedure  to  transfuse 
whole  blood  to  any  patient  in  whom  a  secondary  hemorrhage 
occurs.  A  further  danger  is  the  possibility  that  the  trachea 
may  collapse  as  a  result  of  the  increased  pressure  in  the 
surrounding  tissues.  If  this  occurs,  a  tracheotomy  must  be 
performed,  a  procedure  which  in  itself  carries  a  high  mortal- 
ity rate. 

Infection  of  the  wound  is  treated  by  opening  the  wound 
widely  upon  the  first  indication  and  packing  with  plain 
sterile  gauze.  After  twenty-four  hours  hourly  irrigations 
with  Dakin  solution  are  instituted,  with  hot  sterile  dressings 
applied  directly  to  the  surface  during  the  interim.  When 
the  infection  is  entirely  cleared  away  a  secondary  closure 
is  made. 

A  spurious  form  of  tetany  which  appears  after  from 
two  to  twenty-four  hours  is  not  altogether  uncommon. 
The  symptoms  are  a  slight  tingling  of  the  finger-tips;  an 
itching  of  the  nose.  One  may  notice  a  slight  pallor  about 
the  mouth  and  the  fingers  are  flexed.  There  is  also  moder- 
ate spasticity  of  the  muscles  of  the  forearms  and  lower  ex- 
tremities. This  condition  is  due  to  a  transient  cessation  of 
the  normal  physiologic  function  of  the  parathyroid  bodies 
produced  either  by  trauma  of  their  nerve  supply  or  by  the 
edema  which  results  from  operative  procedures  in  their 


272  THE   THYROID    GLAND 

immediate  vicinity.  This  condition  will  clear  up  spon- 
taneously within  from  six  to  forty-eight  hours,  but  we 
usually  supplement  nature's  endeavor  at  reconstruction 
by  the  administration  of  parathyroid  extract  in  yV-grain 
doses,  three  times  daily,  together  with  30  grains  of  cal- 
cium lactate  every  four  hours,  continuing  this  treatment 
for  two  days.  We  have  seen  this  condition  present  at  the 
end  of  an  operation.  The  condition  disappeared  sponta- 
neously after  one  hour  and  did  not  reappear  during  the 
convalescence. 

The  following  instructions  are  given  routinely  to  all 
exophthamlic  patients  on  leaving  the  hospital: 

"The  following  instructions  should  be  very  carefully 
followed  by  the  patient  in  order  to  receive  the  maximum 
benefit  from  the  operation: 

"1.  The  diet  should  be  a  simple  one,  and  tea,  coffee, 
red  meats,  and  highly  seasoned  or  stimulating  foods  should 
not  be  taken.  Milk,  eggs,  cereals,  vegetables,  and  water 
may  be  taken  in  large  quantities. 

"2.  No  social  functions. 

"3.  Reduce  household  cares  to  the  minimum. 

"4.  Spend  as  much  time  as  possible  in  the  open  air. 

"5.  Avoid  excitement. 

"6.  Walking  in  moderation;  avoid  exertion. 

"7.  Rest  should  be  taken  as  follows:  First  month: 
Arise  at  10.30,  breakfast  in  bed;  rest  again  from  2  to  5, 
retire  at  9.  Second  month:  Arise  at  10;  in  bed  2  to  4. 
Third  and  fourth  months:  Arise  at  9.30;  rest  from  2  to  4. 

"8.  Continue  this  until  your  attending  physician  has 
found  that  you  have  received  your  full  benefit  from  the 
treatment. 

"9.  Report  to  me  your  condition  at  the  end  of  the 
first  and  the  third  month.  Afterward  every  six  months 
for  three  years." 


THE  PROTECTION  OF  THE  PATIENT  IN  SURGERY  OF 
THE  THYROID 

GEORGE  W.  CRILE 


THE  problem  of  the  goiter  patient  becomes,  in  effect, 
the  problem  of  the  patient  with  exophthalmic  goiter,  since 
any  plan  of  management  which  can  safely  be  applied  to  an 
extreme  case  of  exophthalmic  goiter  can  readily  be  modified 
to  meet  the  requirements  of  the  individual  case  with  a 
goiter  of  any  type,  or  with  exophthalmic  goiter  of  any 
degree  of  severity. 

As  has  been  indicated  throughout  the  sections  of  this 
volume,  the  key  to  the  successful  treatment  of  exophthalmic 
goiter  is  protection.  To  the  extent  that  the  protection  of 
the  patient  is  achieved  to  that  extent  is  his  recovery  assured. 

Against  what  is  the  exophthalmic  goiter  patient  to  be 
protected?  He  should  be  protected  against  the  fatally 
excessive  metabolism  which  the  operation  tends  to  induce, 
against  failure  of  the  already  weakened  myocardium, 
and  against  acidosis. 

These  factors  may  be  regarded  as  end-effects  of  impair- 
ment or  failure  of  the  internal  respiration  of  the  organism. 
The  total  activity  of  the  cell — of  the  liver,  of  the  brain,  of 
the  myocardium — may  be  regarded  as  its  internal  respira- 
tion. What  does  the  cell  require  to  assure  the  maintenance 
of  its  normal,  orderly,  internal  respiration?  The  cell  re- 
quires a  normal  supply  of  oxygen;  a  normal  supply  of  fresh 
water;  a  normal  supply  of  food — mostly  in  the  form  of 
glucose. 

What  is  the  probable  state  of  the  cells  of  the  myocardium, 

18  273 


274  THE    THYROID    GLAND 

of  the  brain,  and  of  the  liver  in  cases  of  advanced  exoph- 
thalmic goiter?  The  permeability  of  the  membranes  of  the 
cells  is  probably  greatly  increased,  as  is  indicated  by  the 
effect  of  iodism  on  their  electric  conductivity.  That  is  to 
say,  the  cells  of  the  organs  are  excessively  sensitive,  and 
therefore  the  patient  must  be  protected  against  the  psychic 
stimuli  of  fear  and  worry  before,  during,  and  after  the  opera- 
tion. This  is  accomplished  by  establishing  confidence,  by 
preventing  knowledge  of  the  time  of  the  operation,  by  the 
exclusion  of  anesthetics  that  produce  a  stage  of  excitation. 

The  abnormal  sensitization  of  the  cells  in  exophthalmic 
goiter  cases  necessitates  the  protection  of  local  anesthesia, 
even  if  surgical  anesthesia  is  employed  also. 

These  sensitized  patients  require  protection  against 
any  infection  stimuli;  and,  in  extreme  cases,  they  must  be 
guarded  against  even  the  absorption  of  aseptic  wound 
secretion  or  of  hemoglobin. 

In  brief,  these  patients  must  be  guarded  against  psychic, 
traumatic,  biochemic,  and  anesthetic  stimuli;  against  sub- 
oxidation,  and,  in  addition,  against  the  effects  of  the  secre- 
tion •  of  the  thyroid  itself.  Whether  the  operation  is  to 
be  performed  with  the  patient  in  bed  or  in  the  operating 
room,  on  the  day  of  operation  he  should  see  no  surgeon, 
should  see  no  preparation,  should  see  no  operating  room, 
but  should  see  only  the  already  familiar  anesthetist,  the 
already  familiar  anesthetic  apparatus;  should  experience 
only  the  already  familiar  odor  of  the  gas  and  oxygen,  and 
the  already  familiar  sensation  of  this  type  of  anesthesia. 
The  end  to  be  achieved  is  the  maintenance  of  an  unbroken 
state  of  negativity  while  the  exquisitely  sensitized  organism 
is  carried  through  the  processes  of  the  ligation  of  an  artery, 
and  of  the  removal  of  a  part  of  one  or  both  lobes  of  the 
thyroid. 


PROTECTION  OF  PATIENT  IN  SURGERY  OF  THYROID   275 

In  the  absence  of  other  damaging  influences,  to  be  dis- 
cussed presently,  the  internal  respiration,  and  hence  the 
function  of  the  myocardium,  of  the  cells  of  the  nervous 
system,  and  of  the  cells  of  the  liver  is  not  disturbed  by 
the  operation;  the  appearance  of  the  clinical  chart  is  not 
disturbed;  the  patient  is  safe. 

Protection  against  excitation  and  against  excessive 
activity  is  not  the  only  protection  required  by  the  exoph- 
thalmic goiter  patient.  Protection  against  suboxidation 
is  required  also.  The  internal  respiration,  hence  the  life 
of  the  patient,  is  immediately  dependent  upon  a  continuous 
supply  of  oxygen;  hence  asphyxia,  or  deep  inhalation  anes- 
thesia, quickly  suppresses  the  internal  respiration,  and 
causes  death,  either  immediately  or  within  a  few  hours 
or  a  day  or  more.  The  clinical  course  in  such  a  case  is 
similar  to  that  produced  by  fear,  worry,  physical  injury, 
exertion,  or  infection.  Since  all  inhalation  anesthetics 
cause  suboxidation  in  extreme  cases,  deep  surgical  anes- 
thesia, especially  ether  anesthesia,  is  ruled  out.  Gas  and 
oxygen  analgesia,  combined  with  local  anesthesia,  is  entirely 
free  from  this  serious  objection.  Ether  anesthesia  almost 
wholly  suspends  the  internal  respiration  and  is  especially 
damaging. 

As  regards  the  adaptation  of  the  degree  of  anesthesia 
to  the  individual  patient,  the  judgment  of  a  highly  experi- 
enced anesthetist  is  priceless.  In  this  respect  the  judgment 
of  Miss  Hodgins,  chief  anesthetist  of  Lakeside  Hospital,  is 
almost  unfailing. 

A  weak  myocardium  or  a  decompensated  heart  leads  to 
serious  suboxidation  because  of  the  diminished  minute 
volume  of  blood  supplied  to  the  vital  organs.  Against  this 
condition  the  patient  is  best  protected  by  one  or  two  courses 
of  digitalis  as  described  in  the  preceding  section. 


276 


THE    THYROID    GLAND 


A  much  neglected  requirement  for  the  maintenance 
of  the  normal  internal  respiration  is  water.  Advanced 
cases  of  exophthalmic  goiter  commonly  have  cycles  of 


Fig.  102. — Patient  before  and  after  removal  of  large  bilateral  goiter. 


Fig.  103. — Patient  before  and  after  removal  of  large  pendulous  goiter.     (Case 
of  Dr.  F.  E.  Bunts.) 

vomiting.  These  may  be  controlled  by  sufficient  water,  for 
water  seems  to  bear  some  relation  to  the  cause  of  vomiting, 
which  rarely  occurs  if  a  good  water  equilibrium  is  main- 


PROTECTION  OF  PATIENT  IN  SURGERY  OF  THYROID   277 

tained.  It  is  probable  that  the  clinician  fails  to  appreciate 
the  great  loss  of  water  through  the  skin,  and  that  because 
of  the  raging  metabolism  the  exophthalmic  goiter  case 
requires  much  more  water  than  a  normal  individual;  just 
as  an  engine  running  under  full  pressure  at  60  miles  an  hour 
requires  more  water  than  an  engine  running  only  25  miles 


Fig.  104. — Patient  before  and  after  removal  of  large  vascular  goiter. 

an  hour.  The  goiter  case,  like  the  express  engine,  must 
be  protected  against  burning  out  his  "boiler"  by  urging 
water  by  the  mouth;  or,  if  enough  cannot  be  introduced 
by  this  normal  route,  then,  under  the  protection  of  local 
anesthesia,  from  3000  to  4000  c.c.  may  be  given  subcuta- 
neously  every  twenty-four  hours  until  the  crisis  is  past. 


278 


THE   THYROID   GLAND 


There  is  evidence,  although  it  is  not  conclusive,  that 
the  patient  should  be  protected  against  the  too  sudden 
withdrawal  of  thyroid  activity.  This  danger  may  be 
eliminated  by  the  administration  of  thyroid  extract  before 


Fig.  105. — Patient  before  and  thirty  days  after  removal  of  adenoma. 


ABC 
Fig.  106. — Patient  before  and  after  thyroidectomy  for  exophthalmic  goiter: 
A,   Before   operation.     B,    Two   weeks   after   operation.     C,   A   year  after 
operation. 

the  operation.  By  giving  two  grains  the  evening  before  and 
two  grains  on  the  morning  of  the  operation  the  dose  will 
become  effective  at  the  time  the  thyroidectomy  is  per- 
formed. If,  later,  the  patient  seems  apathetic,  it  is  well  to 
continue  the  administration  of  the  thyroid  extract  for 


PROTECTION    OF    PATIENT    IN    SURGERY    OF    THYROID      279 

some  days.  The  necessity  for  providing  a  more  or  less 
gradual  decline  rather  than  a  sudden  decrease  in  the  amount 
of  the  thyroid  hormone  is  supported  also  by  the  fact  that 
the  safest  operation  is  a  graded  operation:  first,  a  ligation 
of  one  superior  thyroid  artery;  then,  of  a  second;  and 
finally,  after  an  interval,  the  length  of  which  is  determined 
by  the  needs  of  the  individual  patient,  a  unilateral  or  a 
bilateral  partial  thyroidectomy.  In  a  serious  situation, 
even  if  we  could  "wish  out"  the  thyroid,  the  sudden  break 
might  be  fatal. 

In  great  hazards  in  which,  after  the  preliminary  liga- 
tions,  a  period  of  physiologic  rest  has  brought  insufficient 
improvement,  the  thyroidectomy  is  performed  with  the 
patient  in  bed  under  analgesia  and  local  anesthesia  in  order 
that  the  already  impaired  internal  respiration  may  be  pro- 
tected to  the  utmost  from  too  prolonged  general  anes- 
thesia or  from  the  slight  disturbance  which  attends  transit 
to  the  operating  room,  even  when  the  transit  is  made 
with  the  patient  under  anesthesia.  Quinin  and  urea  hydro- 
chlorid  is  used  to  protect  the  patient  against  postoperative 
pain. 

If  the  hazard  is  great  and  the  pulse  runs  up  during  the 
operation  the  wound  is  left  open  to  protect  the  patient 
from  the  absorption  of  wound  secretions  and  from  post- 
operative pain,  and  also  to  shorten  a  hazardous  operation 
by  a  few  but  possibly  decisive  minutes.  The  open  wound 
is  protected  by  flavine  gauze  dressings,  or  by  sterile  dress- 
ings which  protect  the  wound  almost  as  well,  until  its 
closure  under  analgesia  on  the  afternoon  of  the  same  day 
or  on  the  following  morning.  This  affords  a  graded  surgical 
contact. 

Finally,  and  of  the  greatest  importance,  the  patient 
must  be  protected  against  the  so-called  postoperative 


280  THE    THYROID    GLAND 

hyperthyroidism.  Therefore,  if  after  operation  there  is 
inaugurated  a  progressively  increasing  temperature,  with 
a  greatly  increased  respiratory  and  pulse-rate,  then,  in 
accordance  with  the  principle  that  heat  increases  chemical 
activity  and  electric  conductivity,  and  that  increased  chem- 
ical activity  and  increased  conductivity  in  turn  are  expressed 
in  increased  temperature,  such  patients  are  literally  packed 
in  ice.  This  procedure  has  been  found  to  exercise  a  remark- 
able control  over  the  destroying  metabolism. 

This  postoperative  phase  of  exophthalmic  goiter  is 
closely  analogous  to  heat-stroke  in  symptoms  and  in  con- 
trol. It  is  suggestive  to  note  that  both  heat-stroke  and 
the  so-called  postoperative  hyperthyroidism  are  the  antith- 
esis of  shock,  in  which  by  contrast  the  heat  center  is 
paralyzed.  In  the  treatment  of  shock,  heat  is  as  useful 
as  cold  in  the  treatment  of  hyperthyroidism  or  of  heat- 
stroke. In  each  case  the  most  efficient  treatment  is  based 
upon  simple  physical  laws. 

In  brief,  the  goiter  patient  should  be  protected  against 
suboxidation ;  against  inhalation  anesthesia;  against  absorp- 
tion of  wound  secretions;  against  infection;  against  fear  and 
worry;  against  postoperative  hyperthyroidism;  against 
postoperative  hypothyroidism. 

When  protection  against '  these  dangers  is  assured  the 
operability  of  the  goiter  patient,  even  of  the  "bad  risk" 
patient  with  hyperthyroidism,  becomes  100  per  cent.; 
and  the  mortality  is  reduced  to  that  attending  the  removal 
of  benign  pelvic  tumors. 

The  formulation  of  the  plan  of  treatment  described 
in  this  volume  has  been  based  upon  experimental  researches 
and  upon  the  clinical  study  of  3535  thyroidectomies,  among 
which  1958  were  clinically  diagnosed  as  cases  of  exophthal- 
mic goiter. 


PROTECTION  OF  PATIENT  IN  SURGERY  OF  THYROID   281 

In  a  study  of  the  clinical  histories  of  1200  consecutive 
cases  the  following  statistics  were  made: 

185  were  males,  1015  females.    The  ages  of  the  patients 
in  this  group  were  distributed  as  follows: 
75  under  twenty  years  of  age. 

205  between  the  ages  of  twenty  and  thirty. 

345  between  the  ages  of  thirty  and  forty. 

279  between  the  ages  of  forty  and  fifty. 

256  between  the  ages  of  fifty  and  sixty. 
40  above  sixty  years  of  age. 

Among  the  possible  etiologic  factors  mentioned  in  the 
records  a  preceding  infection — in  most  cases  either  tonsillitis 
or  influenza — is  noted  in  278  cases;  " extreme  worry"  in  319; 
fright  and  resultant  nervousness  in  154.  Among  the 
" psychic"  factors  are  mentioned  "sudden  shock  and  ex- 
treme fright  from  automobile  accident";  "sad  news"; 
" severe  grief";  "extreme  financial  worry." 

In  this  series  the  types  of  gland,  following  Dr.  Graham's 
classification,  were  as  follows: 

Normal 14 

Hypertrophy  and  hyperplasia 384 

Colloid  goiter 87 

Exhaustion,  atrophy,  fibrosis 2 

Adenoma,  benign  (unclassified) 182 

(1)  Diffuse  colloid  adenomatous  goiter 175 

f  Pure  fetal 150 

(2)  Fetal  j  Intermediate 72 

i  Colloid 87 

Adenoma,  malignant 11 

Carcinoma 10 

Inflammation 25 

MiliarjT  tuberculosis  of  thyroid 1 

The  involvement  of  the  thyroid  was  bilateral  in  973 
cases;  the  right  lobe  alone  was  involved  in  134;  the  left  lobe 
alone  in  83;  the  middle  lobe  alone  in  10. 

Among  these  1200  histories  some  vocal  complication  is 


282  THE    THYROID    GLAXD 

mentioned  in  51  cases;  hoarseness  is  noted  in  94  of  the 
histories,  and  cough  in  87. 

Since  the  adoption  of  the  methods  described  in  this 
volume  we  have  performed  1783  thyroidectomies,  including 
1022  thyroidectornies  for  exophthalmic  goiter,  with  25  deaths, 
a  mortality  rate  of  1.4  per  cent.;  and  783  ligations  with  6 
deaths,  a  mortality  rate  of  0.76  per  cent. 

Included  in  this  series  are  the  following  groups:  One 
series  of  194  and  another  of  331  consecutive  thyroidectomies 
without  a  death;  one  series  of  153  and  another  of  396  con- 
secutive ligations  without  a  death. 

Since  the  adoption  of  this  plan  of  treatment  no  case  has 
been  rejected  as  inoperable,  although  some  have  been 
practically  in  extremis,  with  edema  of  the  extremities  and 
with  ascites. 


INDEX 


ACHOXDROPLASIA,  91 

Adami,  163 
Adenoma,  81-82 
diffuse  colloid,  41 
fetal  41,  43 
malignant,  43,  45 
Adenomata,  hyperactive,  32 

relation    to    cardiac    disturbances, 

50-54 
toxic,  32 

symptoms  of,  33 

Adrenalin,  effect  on  electric  conduc- 
tivity of  brain,  28 
on  temperature  of  brain,  23 
effects  of,  27 
in  hyperthyroidism,  24 
sensitization  test,  for  hyperthyroid- 
ism, 99-103 

Adrenahsm.   increased   by  hyperthy- 
roidism. 27 
relation    to    hyperthyroidism    and 

iodism,  27 
Adrenals,  role  in  exophthalmic  goiter, 

27-29 
Age,  effect  on  basal  metabolism  rate, 

144 

Angina  in  goiter,  53 
Aphonia,  255 
Artery,  superior  thyroid,  ligation  of, 

235 

tying  outside  capsule,  244 
Arthorva  Veda,  160 
Asthenia,  basal  metabolism  rate  in. 

157-158 
Asthma,  effect  on  basal  metabolism 

rate.  147 

Atrophy  of  thyroid,  40 
Aub,  148,  186,  189,  191 
Auricular  fibrillation,  preoperative 

treatment  of,  270 
flutter  in  goiter.  53 


BAMBERGER,  51 
Barton,  163 

Basal   metabolism,    abnormal    condi- 
tions causing  increase  in  rate, 
146-147 
conditions  causing  a  decrease  in 

rate,  157-158 
definition  of,  142-144 
history  of  study  of,  141-142 
in  exophthalmic  goiter,  87 
normal    factors    affecting    rate, 

144-145 

Basedow,  49,  166 

Basedow's    disease.      See    Exophthal- 
mic goiter. 
Baumann,  167,  169 
Benedict,  141 
Berkman,  187 
Blood  changes  in  exophthalmic  goiter, 

85 

Blood-pressure  in  goiter,  54 
Boggs,  187 
Boothby,  112,  148 
Brendel,  165 

Bronchitis,    postoperative    complica- 
tion, 270 

CARCINOMA  of  thyroid,  45,  47,  259-261 
Cardiac    decompensation,     preopera- 
tive treatment  for,  270 
disturbance,  relation  to  adenomata, 

50-54 

of  intrathoracic  goiter,  80 
dyspnea,  effect  on  basal  metabolism 

rate,  147 
Carman,  130 
Clark,  164 
Coindet,  167 
Coleman,  146 

Colloid  goiter,  39-40,  68-70 
diffuse.  41 


283 


284 


INDEX 


Conductivity.  See  Electric  conduc- 
tivity. 

Coughing  of  intrathoracic  goiter,  78 

Cretinism,  effect  on  basal  metabolism 
rate,  157 

Crotti,  17 

Cysts,  thyroid,  36 

DACOSTA,  88 

Dalrymple's  sign,  84 

Decompression  for  inoperable  cancer 
of  thyroid,  259-261 

Deferred  closure  in  thyroidectomy, 
237-239,  248-251 

Diabetes  mellitus,  effect  on  basal 
metabolism  rate,  146 

Diarrhea,  postoperative,  270 

Differential  diagnosis  of  hyperthy- 
roidism,  88-89 

Digestion,  effect  on  basal  metabolism 
rate,  145 

Digestive  disturbances  in  exophthal- 
mic goiter,  86 

Dilated  ,or  elongated  aorta,  radio- 
graphic  differentiation  from  intra- 
thoracic goiter,  123 

Du  Bois,  D.,  142 

Du  Bois,  E.  F.,  142,  144,  146,  148 

Dyspnea  of  intrathoracic  goiter,  78 

ELECTRIC  conductivity  increased  by 

iodin,  23 

of  brain,  effect  of  adrenalin  on,  28 
Electrochemical  mechanism,  22 
Enchondroma   of   chest  wall,    differ- 
ential diagnosis  of,  128 
Endemic   goiter,    definition   and   his- 
tory of,  160-161 
distribution  of,  161-163 
etiology  of,  171-172 
possibility  of  universal  elimina- 
tion, 180-181 

Esophageal  carcinoma,  radiographic 
differentiation  from  intrathoracic 
goiter,  136 

diverticulum,  radiographic  differen- 
tiation from  intrathoracic  goiter. 
133 

Excitement,  effect  on  basal  metabol- 
ism rate,  145 


Exercise,  effect  on  basal  metabolism 

rate,  145 
Exophthalmic  goiter,  82-89 

adrenalin    sensitization    test    for 

hyperthyroidism,  99-103 
advantages   of  x-ray   treatment, 

86 

basal  metabolism  in,  147-153 
nursing    care,    preoperative    and 

postoperative,  201-206 
postoperative  treatment  of,  263- 

266 

routine,  preoperative,  195-199 
role  of  adrenals  in,  27-29 
serum  test  for,  105-107 
treatment  of,  153-157 
Eye  signs  in  exophthalmic  goiter,  84 

FEVERS,  effect  on  basal  metabolism 
rate,  146 

Fibrosis  of  thyroid,  40 

Fluoroscope  in  diagnosis  of  intra- 
thoracic goiter,  116-122 

Fodere,  161 

GOETSCH  test.  24,  99-103 
Goiter,  colloid,  39-40,  68-70 

endemic,  definition  and  history  of, 

160-161 

distribution  of,  161-163 
etiology  of,  171-172 
possibility  of  universal  elimina- 
tion, 180-181 
exophthalmic,  82-89 

nursing    care,    preoperative    and 

postoperative,  201-206 
routine,  preoperative,  195-199 
incidence  in  the  U.  S.,  163-166 
intrathoracic,  70-80 
practical  application  of  principles  of 

prevention,  173-175 
prevention  of,  169-171 
prophylactic  treatment,  effects  of, 

175-178 
method  of  administration,  178- 

180 

possible  ill  effects,  180 
simple,  67-68 
Graves,  49,  166 


INDEX 


285 


Graves'    disease.      See    Exophthalmic 

goiter. 
Gull,  166 

HALL,  164 

Halsted,  169 

Heart-block  in  goiter,  53 

Helm,  165 

Hemorrhage,  postoperative,  271 

Hildebrand,  187 

Hoarseness,  postoperative,  254 

Hodgkin's  disease,  radiographic  dif- 
ferentiation from  intrathoracic  goi- 
ter, 126-127 

Holmes,  131 

Horsley,  167 

Hyperiodism,  chronic,  23 

Hyperplasia,  pathology  of,  38-39 

Hyper thyroidism,  82-89 

adrenalin  sensitization  test  for,  99- 

103 
advantages  of  x-ray  treatment  for, 

186 

partial,  31-34 
relation  to  iodism  and  adrenalism, 

27 

serum  test  for,  105-107 
synonymous    with    chronic    hyper- 

iodism,  23 
treatment  of,  153-157 

Hypertrophy,  pathology  of,  38-39 

Hypoiodism,  chronic,  23 

Hypopituitarism,  differentiation  from 
myxedema,  93 

IcE-pack,  technic  of,  267-269 
Infection,  postoperative,  256,  271 
Inflammations  of  thyroid,  96-97 
Intermittent  respiratory  block,  post- 
operative, 255-256 
Intrathoracic  goiter,  70-80 

diagnosis     by     radiograph     and 

fluoroscope,  109-139 
differential    diagnosis    by    radio- 
graph, 122-136 

lodin,  importance  in  chemistry,  func- 
tion and  histologic  anatomy  of  thy- 
roid, 167-169 

Iodism,  increased  electric  conductiv- 
ity in,  23 


Iodism,   relation  to  hyperthyroidism 

and  adrenalism,  27 
lodoform,   effect   on   temperature   of 

brain,  24 

JACKSON,  62 

KENDALL,  21,  167,  169 
Kerr,  164 
Klinger,  162 
Kocher,  162,  166,  242 
Kottman,  105 
Krumbhaar,  53 

LAPLACE,  141 

Laryngeal   function,    impairment   of, 

55-64 
nerves,    unilateral    impairment   of, 

postoperative,  60-61 
preoperative,  58-60 
Lavoisier,  141 
Lenhart,  17,  159,  167,  170 
Leukemia,  effect  on  basal  metabolism 

rate,  146 
Liebig,  141 

Ligation,  indications  for,  251-252 
reason  for  good  effect  of,  252 
superior  thyroid  artery,  235 
typical,  223-228 
Lillie,  22 
Ludin,  185 

Lung  abscess,  radiographic  differen- 
tiation from  intrathoracic  goiter, 
127-128 

malignant  growth  of,  radiographic 
differentiation  from  intrathoracic 
goiter,  128-131 
Lusk,  141 
Lymphoid  tissue  in  thyroid,  36 

McCARRisoN,  163,  172 

McCaskey,  148 

McKenzie,  167 

Magnus-Levy,  148,  169 

Marine,  17,  21,  24,  32,  35,  159,  163, 

167,  169,  170,  185 

Mayo,  C.  H.,  23,  185,  188,  242,  244 
Mayo  Clinic,  17 
Mayow,  141 
Means,  148,  186,  189,  191 


286 


INDEX 


Medication,  postoperative,  266 

Menstruation,  effect  on  basal  metab- 
olism rate,  145 

Metabolism.    See  Basal  metabolism. 

Meyer,  23 

Moebius'  sign,  84 

Mongolian  idiocy,  91 

Moore,  130 

Miiller,  Friedrich,  147,  148 

Murray,  167 

Myxedema,  89-93 
effect  on  basal  metabolism  rate,  157 
Gull's  etiology  of,  166 
pathology  of,  40 
postoperative,  261 

NERNST,  22 

Nervous  and  mental  disturbances  in 
exophthalmic  goiter,  87 

Neurasthenia,  differentiation  from  hy- 
perthyroidism,  88 

Neurocirculatory  asthenia,  differen- 
tiation from  hyperthyroidism,  88 

Nitrous  oxid-oxygen  analgesia  in  op- 
erations on  thyroid,  213-222 

Novocain  blocking  of  gland  in  thy- 
roidectomy,  234-235 

Nursing  care  in  exophthalmic  goiter, 
201-206 

OLSON,  164 

Operating-room    nurse,    role   in    thy- 

roidectomies,  207-212 
Ord,  167 
Osier,  82,  163 
Oswald,  167,  169 

PARACELSUS,  160,  166 

Paralysis,  bilateral  abductor,  61-64 
unilateral  laryngeal,  59 

Parathyroid  deficiency,  postoperative, 
257-258 

Paroxysmal  tachycardia,  differentia- 
tion from  hyperthyroidism,  89 

Parry-,  49,  166 

Parry's  disease.  See  Exophthalmic 
goiter. 

Pernicious  anemia,  differentiation 
from  myxedema,  93 

Pettenkofer,  141 


Pituitary   disorders,    effect   on   basal 

metabolism  rate,  147 
Plummer,  54 
Pneumonia,  differential  diagnosis  of, 

128 

postoperative  complication,  270 
Postoperative  complications,  enlarge- 
ment of  thyroid  tissue,  257 
hoarseness.  254 
infection,  256,  271 
intermittent    respiratory    block, 

255-256 
methods  for  treatment  of,  267- 

272 

parathyroid  deficiency,  257-258 
thyroid  deficiency,  257 
regimen,  instructions  for,  272 
treatment,      exophthalmic     goiter, 

263-266 
Preglandular  muscles,  division  of,  in 

thyroidectomy,  232-234,  244 
Prophylactic    treatment    for    goiter, 

effect  of,  175-178 
method  and  form  of  administra- 
tion of,  178-180 
possible  ill  effects  of,  180 
Pulmonary    tuberculosis,    differentia- 
tion from  hyperthyroidism,  89 

RECURRENT    laryngeal    nerves,     ab- 
ductor function  of,  56-57 
adductor  group,  56 

Resection,  typical,  228-242 

Respiratory  symptoms  in  exophthal- 
mic goiter,  85-86 

Reverdin,  166 

Rib,    osseous    tumor   of,    differential 
diagnosis  of,  128 

Riedel,  97 

Riesman,  84 

Roos,  169 

Rubner,  141 

Ruggles,  131 

SANCTORIUS,  141 

Sandiford,  148 

Sarcoma  of  thyroid,  47 

Scar,  attachment  to  trachea,  253 

position  of,  228-232 
Schittenhelm,  162 


INDEX 


287 


Serum  test  for  exophthalmic  goiter, 

105-107 
Seymour,  186 
Shepherd,  163 
Simple  goiter,  67-68 
Sinus  arhythmia  in  goiter,  53 
Smith,  165 
Spine,  tumor  of,  differential  diagnosis, 

128 

Stellwag's  sign,  50,  84 
Stokes,  49 
Strumitis,  96-97 

Submucous  resection  for  bilateral  ab- 
ductor paralysis,  63-64 
Superior  thyroid  artery,  ligation  of, 

235 
Sj-mptoms,  adenomata,  82 

colloid  goiter,  68-70 

exophthalmic   goiter  or  hyperthy- 
roidism,  82-88 

intrathoracic  goiter,  78,  80 

malignant  tumor,  95-96 

TACHYCARDIA,  postoperative,  269-270 

Taussig.  54 

Temperature  of  brain,  effect  of  ad- 
renalin on,  23 
of  iodoform  on,  24 
thermocouple  measurement  of,  23 

Tetany,  postoperative  complication, 
271-272 

Thomas,  123 

Trachea,  attachment  of  scar  to,  253 
blood  in,  248 
protection  of,  in  thyroidectomy,  237 

Tracheitis,  postoperative  complica- 
tion, 270 

Thoracic  aneurysm,  radiographic  dif- 
ferentiation from  thoracic  goiter, 
122-123 

Thymus  tumor,  radiographic  differen- 
tiation from  intrathoracic  goiter, 
123,  126 

Thyroid,  anatomy  of,  65-66 
atrophy  of,  40 

carcinoma  of,  45,  47,  259-261 
classification  of  diseases  of,  66-67 

of  gland,  35 

complications  in  tumors  of,  36 
cysts  of,  36 


Thyroid,     deficiency,     postoperative, 

257-258 

exhaustion  of,  40 
fibrosis  of,  40 
function  of,  21-25 
hypertrophy  and  hyperplasia  of,  38- 

39 

in  exophthalmic  goiter,  83-84 
inflammation  of,  96-97 
inflammations  of,  48 
normal,  36,  38 
physiology  of,  166-169 
sarcoma  of,  47 
tumors  of,  94-96 
typical  ligation  of,  223-228 
Thyroidectomy,  advantages  over  x-ray 

therapy,  193 

amount  of  gland  to  leave,  242 
and  singing,  255 
blocking  of  gland   with  novocain, 

234-235 
cause  for  unevenness  of  neck  after, 

253-254 
deferred  closure  after,  237-239,  248- 

251 
division  of  preglandular  muscles  in, 

244 

end-results  of,  192 
indication  for,  252 
interference  with  mechanism  of 

swallowing,  247 
ligation  of  superior  thyroid  artery, 

235 

maintenance  of  a  clear  field,  247-248 
mortality  of,  192 

part  of  gland  not  to  leave,  242-243 
period  of  disability  after,  191-192 
protection  of  patient  in,  273-280 
resection  of  gland,  235-237,  239-242 
respiratory  obstruction  during,  247 
role  of  operating-room  nurse  in,  207- 

212 

statistics  of  1200  cases  of,  281-282 
trachea  in,  237 
turning  out  gland  with  finger,  245- 

246 
tying  bleeding  vessels  on  surface  of 

trachea,  246-247 
use  of  analgesia  in,  213-222 
versus  x-ray  treatment,  251 


288 


INDEX 


Thyroiditis,  48,  96-97 

Thyro-iodin,  hypersecretion  of,  25,  32 

relation  to  adrenalin,  27 
Thyrotoxicosis,  33 
Thyroxin,  hypersecretion  of,  32 
Trousseau,  49 
Tumors  of  thyroid,  94-96 

URINARY  and  genital  symptoms  in  ex- 
ophthalmic goiter,  87 

VASCULAR  symptoms  in  exophthalmic 

goiter,  84-85 
Vasomotor  and  trophic  symptoms  in 

exophthalmic  goiter,  85 


Voit,  141 

Vomiting,  postoperative,  270 

von  Graefe's  sign,  50,  84 

WATERS,  187 

Weichardt,  162 

Wound,  postoperative  care  of,  266 

ar-RAY  in  diagnosis    of    intrathoracic 

goiter,  114-116 
therapy,   advantages  in  hyperthy- 

roidism,  186 
in  treatment  of  inoperable  cancer 

of  thyroid,  261 
versus  thyroidectomy,  251 


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